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Amjad W, Jiang ZG, Lai M. Metabolic dysfunction-associated steatotic liver disease related cirrhosis and incidence of portal vein thrombosis. Eur J Gastroenterol Hepatol 2024; 36:1038-1045. [PMID: 38829950 DOI: 10.1097/meg.0000000000002800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND There is heterogeneous data on whether metabolic-associated steatohepatitis is an independent risk factor for portal vein thrombosis (PVT). We aim to compare the incidence of PVT in patients with cirrhosis with and without metabolic dysfunction-associated steatotic liver disease (MASLD). METHODS This is a single-center retrospective study of patients with cirrhosis seen between 1 January 2016 and 31 January 2021. Patients with a history of hepatocellular cancer, liver transplant, Budd-Chiari syndrome, and intra-abdominal malignancies were excluded. Patients with cirrhosis were followed from their first hepatology visit for 180 days to determine the incidence of PVT. Cox proportional hazard regression was used to determine the relationship between MASLD with PVT. RESULTS We analyzed data from 2785 patients with cirrhosis who met inclusion and exclusion criteria [mean age: 61.0 ± 12.3 years, 44.3% female, 63.8% Whites and mean model for end-stage liver disease-sodium (MELD-Na) score: 11.7 ± 6.1]. MASLD was present in 21.7% of patients. A total of 89 patients developed PVT during the follow-up, which was fewer in patients with MASLD [2.0% vs. 3.5%, P = 0.04, unadjusted heart rate (HR): 0.60, 95% confidence interval (CI): 0.27-0.96, P = 0.04]. After adjusting for the demographics, MASLD-related comorbid conditions and MELD-Na score, MASLD was associated with a lower incidence of PVT as compared to non-MASLD cirrhosis (HR: 0.44, 95% CI: 0.21-0.92, P = 0.03). After adjusting for the indicators of Child-Pugh Turcotte score, the risk of PVT in patients with MASLD compared to non-MASLD was not statistically significant (HR: 0.50, 95% CI: 0.22-1.13, P = 0.096). CONCLUSION PVT incidence was lower in patients with MASLD cirrhosis as compared to non-MASLD cirrhosis. However, the difference was not significantly different after adjusting for liver decompensation.
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Affiliation(s)
- Waseem Amjad
- Liver Disease Department, Beth Israel Deaconess Medical Center
- Clinical Investigation, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Michelle Lai
- Liver Disease Department, Beth Israel Deaconess Medical Center
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Amjad W, Jiang Z, Lai M. Statin use in cirrhosis and its association with incidence of portal vein thrombosis. J Gastroenterol Hepatol 2024; 39:955-963. [PMID: 38273643 DOI: 10.1111/jgh.16495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/23/2023] [Accepted: 01/03/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND AND AIM Statin use has shown a reduction in hepatic decompensation and portal hypertension. Its association with portal vein thrombosis (PVT) incidence is unknown. We aim to compare the incidence of PVT in patients with and without statin use. METHODS We excluded patients with a history of hepatocellular cancer, liver transplants, Budd-Chiari syndrome, and intra-abdominal malignancies. Patients with cirrhosis were followed from their first hepatologist clinical encounter (January 1, 2016, to January 31, 2021) for 180 days to determine PVT incidence. We tested the association of statin use with PVT using 1:1 propensity score (PS) matching and Cox proportional hazard regression. RESULTS We analyzed 2785 patients with cirrhosis (mean age:61.0 ± 12.3 years, 44.3% female, 63.8% White, mean MELD-Na score:11.7 ± 6.1, and statin use:23.1%). A total of 89 patients developed PVT during the follow-up, which was lower in patients with statin use as compared to no statin use (1.3% vs 3.8%, P = 0.001, unadjusted HR:0.28, 95% CI: 0.13-0.62, P = 0.001). After matching for demographics, comorbidities, and hepatic decompensation events, patients with statin use had a lower risk of developing PVT in 180-day follow-up as compared to those without statin use (HR:0.24, 95% CI: 0.10-0.55, P = 0.001). Subgroup analysis showed that statin use was associated with lower PVT incidence in non-NASH (HR: 0.20, 95% CI: 0.07-0.54, P = 0.002) and decompensated cirrhosis (HR: 0.12, 95% CI:0.03-0.53, P = 0.005) than no statin use. CONCLUSION PVT incidence was lower in decompensated cirrhosis patients with statin use than in those with no statin use. However, this finding needs to be further tested in randomized control trials.
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Affiliation(s)
- Waseem Amjad
- Department of Liver Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Zhenghui Jiang
- Department of Liver Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Michelle Lai
- Department of Liver Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Koumar L, Senthamizhselvan K, Barathi D, Verma A, Rao P, Selvaraj J, Sanker V. Portal Vein Thrombosis in Patients With Cirrhosis of the Liver: Prevalence and Risk Factors. Cureus 2023; 15:e50134. [PMID: 38186444 PMCID: PMC10771608 DOI: 10.7759/cureus.50134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
INTRODUCTION Chronic liver disease very often culminates into cirrhosis and its associated complications. One of the serious complications is portal venous thrombosis, which can occur due to a variety of risk factors. One significant factor contributing to portal hypertension is portal vein thrombosis (PVT). In this study, we aimed to investigate the prevalence of PVT among patients with liver cirrhosis in a tertiary hospital and identify the factors associated with this complication. METHODOLOGY This was a cross-sectional observational study of 93 diagnosed liver cirrhosis patients treated at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) hospital in southern India between June 2020 and January 2021. A thorough evaluation of the clinical condition of the patients and associated comorbidities was done. The patients then underwent Doppler ultrasound/CECT/MRI to look for PVT and its extent. The collected data were analyzed using Statistical Product and Service Solutions (SPSS, version 24) (IBM SPSS Statistics for Windows, Armonk, NY). Comparison between two proportions was done using two two-tailed Z-test/Fisher's exact tests. RESULTS Our study found a PVT prevalence of 17.2% in cirrhotic patients, with a higher prevalence of acute PVT than chronic PVT. Ascitic fluid infection, longer duration of cirrhosis, and increased cirrhosis severity were significantly associated with PVT development. We found no significant associations between PVT and gender, hypertension, smoking, diabetes, or the duration of alcohol intake. CONCLUSION This study highlights the importance of early screening for PVT using Doppler USG in all patients diagnosed with cirrhosis. Additionally, anticoagulation therapy for acute PVT may be considered in patients without bleeding risks.
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Affiliation(s)
- Lokesh Koumar
- Cardiology, Wolverhampton Heart and Lung Centre, New Cross Hospital, Wolverhampton, GBR
| | - Kuppusamy Senthamizhselvan
- Medical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Deepak Barathi
- Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Amogh Verma
- Medicine, Rama Medical College Hospital and Research Centre, Hapur, IND
| | - Pallavi Rao
- Internal Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, IND
| | - Jayachandran Selvaraj
- General Internal Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Vivek Sanker
- General Surgery, Noorul Islam Institute of Medical Science and Research Foundation (NIMS Medicity), Trivandrum, IND
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Evaluation of Low-Molecular-Weight Heparin for Treatment of Portal Vein Thrombosis in Liver Cirrhosis Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020292. [PMID: 36837493 PMCID: PMC9965161 DOI: 10.3390/medicina59020292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/29/2023] [Accepted: 02/01/2023] [Indexed: 02/08/2023]
Abstract
Background and Objectives: Even though low-molecular-weight heparin (LMWH), including dalteparin, has a critical role in portal vein thrombosis (PVT) treatment in liver cirrhosis (LC) patients, the predictive factors and the proper dose of dalteparin for PVT treatment and relapse have not yet been investigated. Materials and Methods: This retrospective study evaluated the records of LC patients receiving dalteparin from July 2013 to June 2019. The odds ratio (OR) and adjusted OR were calculated from univariate and multivariable analyses, respectively. Results: Among data from 121 patients, the overall recanalization rate of all patients was 66.1% (80 patients). No history of variceal bleeding (OR 4.6, 95% CI: 1.88-11.43) and the case of newly developed thrombus before dalteparin treatment (OR 3.2, 95% CI: 1.24-8.08) were predictive factors associated with increased treatment response. Relapse of PVT occurred in 32 out of 80 patients (40%) who showed a recanalization. The risk of relapse was 3.1-3.9 times higher in those who took more than three months or more than six months from the diagnosis of PVT to dalteparin treatment compared to those who took less than these durations, respectively. In the dosing regimen, patients with the kg-based dosing regimen showed 2.6 times better response than those with the fixed dosing regimen. However, no difference in bleeding complications was observed. Conclusion: In the dosing regimen, the kg-based regimen that was the same as the venous thromboembolism regimen was a better option for the efficacy and safety of dalteparin therapy. Additionally, when treating PVT in LC patients, careful monitoring is recommended for patients with predictive factors for treatment response and relapse of PVT.
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Transjugular Intrahepatic Portosystemic Shunt in Chronic Portal Vein Thrombosis-From Routine Recommendations to Demanding Scenarios. Diagnostics (Basel) 2022; 12:diagnostics12123100. [PMID: 36553107 PMCID: PMC9777205 DOI: 10.3390/diagnostics12123100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
Portal vein thrombosis (PVT), particularly the presence of portal cavernoma, was traditionally considered a relative contraindication for transjugular intrahepatic portosystemic shunting (TIPS) due to the technical difficulties in accessing and maneuvering the portal vein and avoiding the high risk for bleeding periportal collaterals. However, the last decade has seen a surge in the number of studies-mostly case reports and small series of patients-demonstrating that TIPS is not only technically feasible in the vast majority of these patients but also provides effective and long-term control of symptoms associated with portal hypertension in cases refractory to the standard line of therapy. The present article aims to provide a concise but exhaustive overview of the role and the standard and technically difficult TIPS placement scenarios in patients with chronic non-malignant PVT and with and without underlying liver disease. The review is strategically punctuated by exemplary instances from the authors' experience.
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Interventional Management of Portal Hypertension in Cancer Patients. Curr Oncol Rep 2022; 24:1461-1475. [PMID: 35953600 DOI: 10.1007/s11912-022-01319-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of the classifications and clinical hallmarks of common cancer-related conditions that contribute to the high incidence of portal hypertension in this population and provide an update on currently available interventional radiology therapeutic approaches. RECENT FINDINGS In the last few decades, there have been significant advancements in understanding the pathophysiology of portal hypertension. This knowledge has led to the development of safer and more effective minimally invasive approaches. The main objective is to provide alternatives to prevent life-threatening complications from clinically significant portal hypertension and to allow the continuation of cancer treatment interventions that would otherwise be stopped. Clinicians involved in cancer care should be aware of risk factors, associated complications, and management of portal hypertension in cancer patients. Interventional radiology offers minimally invasive alternatives that play a central role in improving clinical outcomes and survival of these patients, allowing the continuation of cancer treatments.
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Ali JS, Kinden RH, Emsley JG. A Case of Septic Portal Vein Thrombosis in a 71-Year-Old Female. Cureus 2022; 14:e27256. [PMID: 36039235 PMCID: PMC9402396 DOI: 10.7759/cureus.27256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
Portal vein thrombosis (PVT) is a relatively rare condition that is characterized by partial or complete occlusion of the portal vein. The most common risk factors for developing PVT are a result of a low intra-hepatic vein flow or pro-thrombotic states, including underlying liver disease, coagulopathies, infection, and malignancy. Patients with PVT can present asymptomatically, while others are in profound shock. Clinical manifestations vary based on the location of the thrombus, degree of occlusion, and if it has become infected. Although an uncommon source of sepsis in the emergency department (ED), maintaining a high degree of clinical suspicion for septic PVT is critical as there are additional treatment considerations apart from early antibiotic therapy as in general sepsis. The following case report focuses on a 71-year-old woman with a septic PVT who presented to the ED with fever and hypotension in the absence of known risk factors. Current management guidelines and evidence regarding treatment strategies for septic PVT are also discussed in further detail.
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Zheng Z, Yu Q, Peng H, Zhang W, Shen Y, Feng H, Huang L, Zhou F, Zhang Q, Wang Q. Research on Portal Venous Hemodynamics and Influencing Factors of Portal Vein System Thrombosis for Wilson’s Disease after Splenectomy. Front Surg 2022; 9:834466. [PMID: 35706848 PMCID: PMC9189385 DOI: 10.3389/fsurg.2022.834466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/03/2022] [Indexed: 11/21/2022] Open
Abstract
Objective Splenectomy is one crucial solution for hypersplenism with portal hypertension. However, portal vein system thrombosis (PVST) caused by hemodynamic changes affects the prognosis of patients. We analyze the changes in portal vein hemodynamics following splenectomy for Wilson’s disease combined with portal hypertension and the influencing factors that lead to PVST. Methods A retrospective cohort study was conducted, in which 237 Wilson’s disease patients with hypersplenism underwent splenectomy. The hemodynamic indices of the portal vein were monitored before surgery and on the 1st, 7th, and 14th days around surgery. The patients were divided into PVST and non-PVST groups. The clinical factors were identified by univariate and multivariate logistic regression. The Logit P was calculated according to the logistic regression prediction model, and the ROC curve for each independent factor was plotted. Results The portal vein velocity, flow, and inner diameter showed a downward trend around surgery, with statistically significant differences between each time point (P < 0.01). The PVST incidence rate was 55.7%. Univariate analysis revealed that the platelet (PLT) levels on the postoperative 3rd and 7th days (P = 0.001; P < 0.001), D-dimer (D-D) on the postoperative 7th and 14th days (P = 0.002; P < 0.001), preoperative portal vein velocity, flow, diameter (P < 0.001), and splenic vein diameter (P < 0.001) were all statistically and significantly different between the two groups. Multivariate logistic regression revealed a significant increase in PLT on the postoperative 7th day (OR = 1.043, 95% CI, 1.027–1.060, P < 0.001) and D-D on the postoperative 14th day (OR = 1.846, 95% CI, 1.400–2.435, P < 0.001). Preoperative portal and splenic vein diameters (OR = 1.565, 95% CI, 1.213–2.019, P = 0.001; OR = 1.671, 95% CI, 1.305–2.140, P < 0.001) were the risk factors for PVST. However, preoperative portal vein velocity and flow (OR = 0.578, 95% CI, 0.409–0.818, P = 0.002; OR = 0.987, 95% CI, 0.975–0.990, P = 0.046) were protective factors for PVST. Logit P was calculated using a logistic regression prediction model with a cut-off value of −0.32 and an area under receiver operating characteristic curve of 0.952 with 88.61% accuracy. Conclusions Splenectomy relieves portal hypertension by reducing the hemodynamics index. PVST is linked to multiple factors, including preoperative portal vein diameter, velocity, flow, and splenic vein diameter, especially PLT on the postoperative 7th day and D-D on the postoperative 14th day. The predictive model is accurate in predicting PVST.
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Affiliation(s)
- Zhou Zheng
- The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
- Institute of Chinese Medicine Surgery, Anhui Academy of Chinese Medicine, Hefei, China
| | - Qingsheng Yu
- The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
- Institute of Chinese Medicine Surgery, Anhui Academy of Chinese Medicine, Hefei, China
- Correspondence: Qingsheng Yu
| | - Hui Peng
- The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
- Institute of Chinese Medicine Surgery, Anhui Academy of Chinese Medicine, Hefei, China
| | - Wanzong Zhang
- The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
- Institute of Chinese Medicine Surgery, Anhui Academy of Chinese Medicine, Hefei, China
| | - Yi Shen
- The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
- Institute of Chinese Medicine Surgery, Anhui Academy of Chinese Medicine, Hefei, China
| | - Hui Feng
- The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
- Institute of Chinese Medicine Surgery, Anhui Academy of Chinese Medicine, Hefei, China
| | - Long Huang
- The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
- Institute of Chinese Medicine Surgery, Anhui Academy of Chinese Medicine, Hefei, China
| | - Fuhai Zhou
- The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
- Institute of Chinese Medicine Surgery, Anhui Academy of Chinese Medicine, Hefei, China
| | - Qi Zhang
- The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
- Institute of Chinese Medicine Surgery, Anhui Academy of Chinese Medicine, Hefei, China
| | - Qin Wang
- The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
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Knight GM, Clark J, Boike JR, Maddur H, Ganger DR, Talwar A, Riaz A, Desai K, Mouli S, Hohlastos E, Garcia Pagan JC, Gabr A, Stein B, Lewandowski R, Thornburg B, Salem R. TIPS for Adults Without Cirrhosis With Chronic Mesenteric Venous Thrombosis and EHPVO Refractory to Standard-of-Care Therapy. Hepatology 2021; 74:2735-2744. [PMID: 34021505 DOI: 10.1002/hep.31915] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/06/2021] [Accepted: 05/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Extrahepatic portal vein occlusion (EHPVO) from portal vein thrombosis is a rare condition associated with substantial morbidity and mortality. The purpose of this study is to investigate the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) for the treatment of chronic EHPVO, cavernomatosis, and mesenteric venous thrombosis in adults without cirrhosis who are refractory to standard-of-care therapy. APPROACH AND RESULTS Thirty-nine patients with chronic EHPVO received TIPS. Laboratory parameters and follow-up were assessed at 1, 3, 6, 12, and 24 months, and every 6 months thereafter. Two hepatologists adjudicated symptom improvement attributable to mesenteric thrombosis and EHPVO before/after TIPS. Kaplan-Meier was used to assess primary and overall TIPS patency, assessing procedural success. Adverse events, radiation exposure, hospital length-of-stay and patency were recorded. Cavernoma was present in 100%, with TIPS being successful in all cases using splenic, mesenteric, and transhepatic approaches. Symptom improvement was noted in 26 of 30 (87%) at 6-month follow-up. Twelve patients (31%) experienced TIPS thrombosis. There were no significant long-term laboratory adverse events or deaths. At 36 months, freedom from primary TIPS thrombosis was 63%; following secondary interventions, overall patency was increased to 81%. CONCLUSIONS TIPS in chronic, noncirrhotic EHPVO with cavernomas and mesenteric venous thrombosis is technically feasible and does not adversely affect liver function. Most patients demonstrate subjective and objective benefit from TIPS. Improvement in patency rates are needed with proper timing of adjuvant anticoagulation.
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Affiliation(s)
- Gabriel M Knight
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Jeffrey Clark
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Justin R Boike
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Haripriya Maddur
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Daniel R Ganger
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Abhinav Talwar
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Ahsun Riaz
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Kush Desai
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Samdeep Mouli
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Elias Hohlastos
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Juan-Carlos Garcia Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders, Hamburg, Germany
| | - Ahmed Gabr
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Brady Stein
- Department of Medicine, Division of Hematology, Northwestern University, Chicago, IL, USA
| | - Robert Lewandowski
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Bartley Thornburg
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Riad Salem
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
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Chun HS, Choe AR, Lee M, Cho Y, Kim HY, Yoo K, Kim TH. Treatment of direct oral anticoagulants in patients with liver cirrhosis and portal vein thrombosis. Clin Mol Hepatol 2021; 27:535-552. [PMID: 34130370 PMCID: PMC8524067 DOI: 10.3350/cmh.2021.0109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/06/2021] [Indexed: 11/30/2022] Open
Abstract
Although patients with cirrhosis are known to be in a state of “rebalance” in that pro- and anticoagulant factors increase the risk for both bleeding and thrombosis, the prevalence of portal vein thrombosis (PVT) in patients with cirrhosis can be up to 26%. Therefore, physicians should consider anticoagulation for the prevention and management of PVT in patients with cirrhosis who are at high risk of PVT. Vitamin K antagonist or low molecular weight heparin is suggested as the standard treatment for PVT in cirrhosis. With the advent of new direct-acting oral anticoagulants (DOACs), there is a paradigm shift of switching to DOACs for the treatment of PVT in patients with cirrhosis. However, the safety and efficacy of DOACs in the treatment of PVT was not well-known in patients with cirrhosis. Therefore, this review focused on the current knowledge about the efficacy, safety concerns, and hepatic metabolism of DOACs in patients with cirrhosis and PVT.
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Affiliation(s)
- Ho Soo Chun
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - A Reum Choe
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Minjong Lee
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hwi Young Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Kwon Yoo
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Tae Hun Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Ewha Womans University Medical Center, Seoul, Korea
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Ilcewicz HN, Martello JL, Piechowski K. Evaluation of the efficacy and safety of direct oral anticoagulants in the treatment of portal vein thrombosis. Eur J Gastroenterol Hepatol 2021; 33:911-916. [PMID: 33079786 PMCID: PMC8371984 DOI: 10.1097/meg.0000000000001958] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the efficacy and safety of direct oral anticoagulants vs. warfarin for portal vein thrombosis treatment. METHODS This was a single-center, retrospective study. Adult patients initiated on a direct oral anticoagulant or warfarin for treatment of a new portal vein thrombosis were included. The primary failure outcome was the absolute difference in recurrent thromboembolic events 90 days following initiation of a direct oral anticoagulant vs. warfarin. The primary safety outcome was the absolute difference in bleeding events 90 days following initiation of a direct oral anticoagulant vs. warfarin. Descriptive statistics, Fisher's exact, and Student's t-tests were utilized as appropriate. RESULTS Thirty-three patients were included. Thirteen (39.4%) patients received direct oral anticoagulants, and 20 (60.6%) received warfarin. None of the patients receiving direct oral anticoagulants experienced a primary failure event compared to four receiving warfarin (P < 0.001). None of the patients receiving direct oral anticoagulants experienced a primary safety event vs. one receiving warfarin (P < 0.001). CONCLUSION Direct oral anticoagulants appear to be effective and safe in the treatment of portal vein thrombosis and in preventing recurrent thromboembolic events. Future studies with larger sample sizes are warranted to confirm direct oral anticoagulants' efficacy in portal vein thrombosis.
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Affiliation(s)
- Haley N. Ilcewicz
- St. Louis College of Pharmacy at University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri
| | - Jay L. Martello
- West Virginia University School of Pharmacy, Morgantown, West Virginia, USA
| | - Kara Piechowski
- West Virginia University Medicine, Morgantown, West Virginia, USA
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Costache RS, Dragomirică AS, Dumitraș EA, Mariana J, Căruntu A, Popescu A, Costache DO. Portal vein thrombosis: A concise review (Review). Exp Ther Med 2021; 22:759. [PMID: 34035856 DOI: 10.3892/etm.2021.10191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/19/2021] [Indexed: 12/14/2022] Open
Abstract
Portal vein thrombosis (PVT) is a frequent complication in cirrhotic patients, but it may also exist as a basic vascular condition even without any liver damage. Local and systemic factors play a significant role in the pathogenesis of PVT; yet, in practice, more than one factor may be identified. PVT can be considered a result of liver fibrosis and hepatic insufficiency. The JAK2 mutation has been accepted as a factor producing PVT. In general, the anticoagulants are recommended but this therapy should be used carefully in treating patients that associate coagulopathy or thrombocytopenia and esophageal varices. Acute PVT without bowel infarction has a good prognosis. In liver cirrhosis, the mortality due to hemorrhage is higher than in chronic PVT. Therefore, for the patients with PVT, the survival rate is decreased by 55% in two years, due to hepatic insufficiency. Regarding the treatment, LMWH (low molecular weight heparine) is the most utilized in patients with cirrhosis, non-malignancies, infections, or those who are awaiting a liver transplant. DOACs (direct-acting oral anticoagulants) may be used in the rest of the medical conditions, being safe and equal to LMWH.
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Affiliation(s)
- Raluca S Costache
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania.,5th Clinical Department, Gastroenterology and Internal Medicine Discipline, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Andreea S Dragomirică
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania
| | - Elena A Dumitraș
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania
| | - Jinga Mariana
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania.,5th Clinical Department, Gastroenterology and Internal Medicine Discipline, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ana Căruntu
- Department of Maxillofacial Surgery, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania
| | - Andrada Popescu
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania.,5th Clinical Department, Gastroenterology and Internal Medicine Discipline, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Daniel O Costache
- Department of Research, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania
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Yao W, Feng Y, Liu T, Li W, Zhang M, Yao Y, Wu S. Rivaroxaban versus low-molecular weight heparin plus warfarin prevents portal vein system thrombosis after splenectomy and pericardial devascularization: A randomized clinical trial. EXCLI JOURNAL 2021; 20:537-549. [PMID: 33883982 PMCID: PMC8056059 DOI: 10.17179/excli2020-3120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/22/2021] [Indexed: 12/20/2022]
Abstract
This study aimed to evaluate the safety and efficacy of rivaroxaban in preventing portal vein system thrombosis (PVST) in patients with liver cirrhosis after splenectomy and pericardial devascularization. 70 cirrhotic patients undergoing splenectomy and pericardial devascularization were randomly assigned to rivaroxaban treatment (n=35) or low-molecular weight heparin (LMWH) plus warfarin treatment (n=35) for 30 days in this randomized controlled trial. The primary endpoint is the PVST formation. Ultrasound doctors and radiologists were blinded to the randomization results. Both groups received routine outpatient inspection every month and were followed for one year. 17 patients (48.6 %) in rivaroxaban group developed PVST, compared with 27 patients (77.1 %) in LMWH plus warfarin group (P=0.025). The incidence of PVST during the first year postoperation was significantly lower in rivaroxaban group than in LMWH plus warfarin group (F=7.901, P=0.006). The intra-group comparisons versus baseline showed the liver function improved from POD 21 to POM 1, and coagulation function improved from POM 2, in rivaroxaban group. In contrast, the liver function improved from POM 1 to POM 2, and coagulation function improved from POM 4, in LMWH plus warfarin group. The prophylactic use of rivaroxaban significantly decreases the incidence of PVST after splenectomy and pericardial devascularization in cirrhotic patients compared to LMWH plus warfarin treatment. Besides, rivaroxaban treatment was safe and effective and associated with better liver and coagulation functions improvement than LMWH plus warfarin treatment.
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Affiliation(s)
- Wei Yao
- Department of Hepatobiliary Surgery, the Affiliated Baoji Hospital of Xi'an Medical University, 4 Qingjiang Road, Baoji, Shaanxi 721006, P.R. China
| | - Yongan Feng
- Department of Hepatobiliary Surgery, the Affiliated Baoji Hospital of Xi'an Medical University, 4 Qingjiang Road, Baoji, Shaanxi 721006, P.R. China
| | - Ting Liu
- Department of Hepatobiliary Surgery, the Affiliated Baoji Hospital of Xi'an Medical University, 4 Qingjiang Road, Baoji, Shaanxi 721006, P.R. China
| | - Wujun Li
- Department of General Surgery, the First Affiliated Hospital of Xi'an Medical University, 48 Fenghao West Road, Xi'an, Shaanxi, 710077, PR China
| | - Mei Zhang
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi 710061, P.R. China
| | - Yingmin Yao
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi 710061, P.R. China
| | - Shengli Wu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi 710061, P.R. China
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14
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Minoda AM, Cadete RBF, Teixeira SR, Muglia VF, Elias Junior J, de Melo-Leite AF. The ABCD of portal vein thrombosis: a systematic approach. Radiol Bras 2020; 53:424-429. [PMID: 33304012 PMCID: PMC7720666 DOI: 10.1590/0100-3984.2019.0109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Portal vein thrombosis refers to complete or partial obstruction of the portal venous system, in the intrahepatic or extrahepatic venous tract or even in the splenic or superior mesenteric veins. This common and potentially fatal condition can develop in various clinical contexts, especially those of liver cirrhosis, hepatocellular carcinoma, and other solid tumors. Certain characteristics, such as the time since the onset of the thrombus (acute or chronic), its biology (hematic or tumoral), the presence of collateral vessels, and the magnetic resonance imaging aspects, are important components of a thorough, careful analysis, as well as informing decisions regarding the appropriate therapeutic strategy. Here, we present a brief review of the anatomy of the portal venous system and a systematic approach to analyzing the condition, using a mnemonic (ABCD, for age, biology, collaterals, and diffusion). We discuss the various imaging methods and illustrate our discussion with images selected from the case files archived at our facility.
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Affiliation(s)
| | | | - Sara Reis Teixeira
- Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Valdair Francisco Muglia
- Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Jorge Elias Junior
- Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Andréa Farias de Melo-Leite
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE, Brazil.,Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil
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15
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Wu M, Schuster M, Tadros M. Update on Management of Portal Vein Thrombosis and the Role of Novel Anticoagulants. J Clin Transl Hepatol 2019; 7:154-164. [PMID: 31293916 PMCID: PMC6609842 DOI: 10.14218/jcth.2018.00057] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 05/07/2019] [Accepted: 05/29/2019] [Indexed: 12/13/2022] Open
Abstract
The clinical management of portal vein thrombosis (PVT) remains ambiguous due to its heterogeneous presentations and its associations with liver disease, malignancy, and hypercoagulable states. The natural history and clinical outcome of PVT are highly variable, dependent upon size, extent and degree of the thrombotic occlusion, as well as the physiological impact of patient comorbidities. While existing clinical guidelines consistently recommend low molecular weight heparin or vitamin K antagonist anticoagulation in cirrhotic patients with symptomatic acute PVT, management of asymptomatic and chronic PVT may need to be determined on a case-by-case basis, factoring in the state of underlying liver disease. In general, patients with PVT and underlying malignancy should be anticoagulated to alleviate symptoms and prevent recurrences that could disrupt the cancer management. However, existing clinical data does not support routine anticoagulation of cirrhotic patients with asymptomatic PVT in the absence of underlying cancer. While low molecular weight heparin and vitamin K antagonist remain the most commonly used agents in PVT, an emerging body of clinical evidence now suggests that direct-acting oral anticoagulants may be used safely and effectively in PVT. As such, direct-acting oral anticoagulants may offer a more convenient anticoagulation alternative for PVT management in future practice.
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Affiliation(s)
| | - Michael Schuster
- Department of Radiology, Albany Medical Center Hospital, Albany, NY, USA
| | - Micheal Tadros
- Department of Gastroenterology, Albany Medical Center Hospital, Albany, NY, USA
- *Correspondence to: Micheal Tadros, Department of Gastroenterology, Albany Medical Center Hospital, 1769 Union St. 2 Floor Niskayuna Medical Arts Building Schenectady, Albany, NY 12308, USA. Tel: +1-551-655-5171, E-mail:
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16
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Iliescu L, Toma L, Mercan-Stanciu A, Grumeza M, Ioanitescu S. Contrast-Enhanced Ultrasonography in the Diagnosis of Portal Vein Thrombosis: A Pictorial Review. Ultrasound Q 2019; 35:311-315. [PMID: 31083039 DOI: 10.1097/ruq.0000000000000451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis is a frequently encountered complication in hepatology and hematology. In patients with liver cirrhosis, it can occur in the natural history of the disease due to clotting disorders or associated with hepatocellular carcinoma. The development of a malignant thrombus is a contraindication to several therapeutic procedures in liver cancer, such as liver resection or transplantation or transarterial chemoembolization; therefore, patients need to be attentively evaluated. Contrast-enhanced ultrasonography is a relatively new noninvasive imagistic investigation with proven accuracy in focal liver lesions. Its use in differentiating malignant and nonmalignant portal vein thrombosis is still controversial. This article revises the characteristics of portal vein thrombosis on contrast-enhanced ultrasonography in order to determine its accuracy in the diagnosis of malignant portal vein thrombosis.
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Affiliation(s)
- Laura Iliescu
- Clinic of Internal Medicine, Fundeni Clinical Institute.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Letitia Toma
- Clinic of Internal Medicine, Fundeni Clinical Institute.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | | | | | - Simona Ioanitescu
- Clinic of Internal Medicine, Fundeni Clinical Institute.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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