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Diesveld MME, Pijnenburg DWMJ, Weersink RA, Barzel I, Drenth JPH, Lisman T, Metselaar HJ, Monster-Simons MH, Mulder MB, Okel E, Taxis K, Borgsteede SD. Recommendations for the safe use of direct oral anticoagulants in patients with cirrhosis based on a systematic review of pharmacokinetic, pharmacodynamic and safety data. Eur J Clin Pharmacol 2024; 80:797-812. [PMID: 38430266 DOI: 10.1007/s00228-024-03648-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/03/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE The popularity of direct oral anticoagulants (DOACs) is increasing among patients with cirrhosis. Cirrhosis has a major impact on the pharmacokinetics of drugs, potentially increasing adverse events. Safe use of drugs in cirrhosis requires a diligent risk-benefit analysis. The aim of this study is to develop practice recommendations for safe use of DOACs in cirrhosis based on a systematic review of pharmacokinetic, pharmacodynamic and safety data. METHODS We conducted a systematic literature search to identify studies on pharmacokinetics, pharmacodynamics and safety of DOACs in cirrhosis. Data were collected and presented in summary tables by severity of cirrhosis using the Child-Turcotte-Pugh (CTP) classification. A multidisciplinary expert panel evaluated the results and classified the DOACs according to safety. RESULTS Fifty four studies were included. All DOACs were classified as 'no additional risks known' for CTP A. For CTP B, apixaban, dabigatran and edoxaban were classified as 'no additional risks known'. Apixaban and edoxaban showed fewer adverse events in patients with cirrhosis, while dabigatran may be less impacted by severity of cirrhosis based on its pharmacokinetic profile. Rivaroxaban was classified as 'unsafe' in CTP B and C based on significant pharmacokinetic alterations. Due to lack of data, apixaban, dabigatran and edoxaban were classified as 'unknown' for CTP C. CONCLUSION DOACs can be used in patients with CTP A cirrhosis, and apixaban, dabigatran and edoxaban can also be used in CTP B. It is recommended to avoid rivaroxaban in CTP B and C. There is insufficient evidence to support safe use of other DOACs in CTP C cirrhosis.
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Affiliation(s)
| | | | - Rianne A Weersink
- Deventer Hospital, Department of Clinical Pharmacy, Deventer, The Netherlands
- Radboud University Medical Center, Department of Pharmacy, Nijmegen, The Netherlands
| | - Ina Barzel
- Erasmus University Medical Center, Department of Hospital Pharmacy, Rotterdam, The Netherlands
| | - Joost P H Drenth
- Radboud University Medical Center, Department of Gastroenterology, Nijmegen, The Netherlands
| | - Ton Lisman
- University of Groningen, University Medical Center Groningen, Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Groningen, The Netherlands
| | - Herold J Metselaar
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands
| | - Margje H Monster-Simons
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
- University of Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Midas B Mulder
- Erasmus University Medical Center, Department of Hospital Pharmacy, Rotterdam, The Netherlands
| | - Eline Okel
- Pharmacy Zorgapotheken Flevoland, Almere, The Netherlands
| | - Katja Taxis
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of Pharmacotherapy, -Epidemiology & -Economics, Groningen, The Netherlands
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2
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Ayoub M, Faris C, Chumbe JT, Daglilar E, Anwar N, Naravadi V. Safety of DOACs in patients with Child-Pugh Class C cirrhosis and atrial fibrillation. JGH Open 2024; 8:e13074. [PMID: 38699468 PMCID: PMC11063728 DOI: 10.1002/jgh3.13074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/20/2024] [Accepted: 04/12/2024] [Indexed: 05/05/2024]
Abstract
Background Anticoagulation (AC) is used for stroke prevention in atrial fibrillation (AF). Direct Oral Anticoagulants (DOACs) are safe in patients with AF without cirrhosis, they are hardly studied in patients with advanced cirrhosis. Our study evaluates the safety and outcomes of DOACs in patients with Child-Pugh class C cirrhosis (CPC). Methods We queried TriNetX Database. Patients with CPC and AF were divided into three cohorts: patients on DOACs, no AC, and warfarin. Three study arms were created using a 1:1 propensity score matching system (PSM). Results Totally 16 029 patients met the inclusion criteria. Of those, 20.2% (n = 3235) were on DOACs, 47.1% (n = 7552) were not on AC, and 32.7% (n = 5242) were on warfarin. First arm comparing AC versus no AC, a statistically significant benefit was identified in 3-year mortality risk (47% vs 71%, P < 0.0001) and transplant status (17% vs 5%, p < 0.0001) with AC. However, no significant difference was identified regarding intracranial hemorrhage and GI bleeding risk. Second arm comparing patients on DOACs versus no AC, we identified mortality benefit (40% vs 72%, P < 0.0001) and a higher transplant rate (9% vs 3.2%, P < 0.0001) with DOACs. Intracranial hemorrhage rates (6% vs 4%, P = 0.03) were higher in patients on DOACs. Third arm comparing patients on DOACs versus Warfarin, a statistically significant lower risk of intracranial hemorrhage (6.6% vs 8.7%, P = 0.004) and GI bleed (2% vs 2.4%, P < 0.0001) were identified in patients on DOACs. Conclusion Anticoagulation is safe in patients with CPC with AF and may provide a mortality benefit. DOACs are a safer alternative to warfarin.
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Affiliation(s)
- Mark Ayoub
- West Virginia University Charleston Division, Internal Medicine DepartmentCharleston Area Medical CenterCharlestonWest VirginiaUSA
| | - Carol Faris
- Marshall University School of MedicineSurgery DepartmentHuntingtonWest VirginiaUSA
| | - Julton Tomanguillo Chumbe
- West Virginia University Charleston Division, Internal Medicine DepartmentCharleston Area Medical CenterCharlestonWest VirginiaUSA
| | - Ebubekir Daglilar
- Department of Gastroenterology, Charleston DivisionWest Virginia University School of Medicine, Charleston Area Medical CenterCharlestonWest VirginiaUSA
| | - Nadeem Anwar
- Department of Gastroenterology, Charleston DivisionWest Virginia University School of Medicine, Charleston Area Medical CenterCharlestonWest VirginiaUSA
| | - Vishnu Naravadi
- Department of Gastroenterology, Charleston DivisionWest Virginia University School of Medicine, Charleston Area Medical CenterCharlestonWest VirginiaUSA
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3
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Elshafey SA, Brown RS. Nonviral or Drug-Induced Etiologies of Acute-on-Chronic Liver Failure (Autoimmune, Vascular, and Malignant). Clin Liver Dis 2023; 27:649-657. [PMID: 37380288 DOI: 10.1016/j.cld.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Vascular, autoimmune hepatitis, and malignant causes of acute-on-chronic liver failure are rare but important to consider and investigate in patients with underlying liver disease who present with acute deterioration and other more common etiologies have been excluded. Vascular processes including Budd-Chiari syndrome and portal vein thrombosis require imaging for diagnosis and anticoagulation is the mainstay of therapy. Patients may require advanced interventional therapy including transjugular intrahepatic portosystemic shunt or consideration of liver transplantation. Autoimmune hepatitis is a complex disease entity that requires a high degree of clinical suspicion and can present heterogeneously.
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Affiliation(s)
- Suzanne A Elshafey
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, 1305 York Avenue, 4th Floor, New York, NY 10021, USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, 1305 York Avenue, 4th Floor, New York, NY 10021, USA.
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4
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Mantaka A, Gatselis N, Triantos CK, Thalheimer U, Leandro G, Zachou K, Konstantakis C, Saitis A, Thomopoulos K, Kouroumalis EA, Dalekos GN, Samonakis DN. Treatment of portal vein thrombosis in cirrhosis: a multicenter real life cοhort study. Minerva Gastroenterol (Torino) 2023; 69:107-113. [PMID: 36856274 DOI: 10.23736/s2724-5985.21.02861-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Portal vein thrombosis (PVT) is a common complication of cirrhosis and can be a cause or consequence of liver disease progression. It is unclear whether PVT treatment is affecting clinical outcomes in cirrhotics. METHODS This is a multicenter study of cirrhotics with PVT, initially retrospectively and thereafter prospectively registered in a data base. We studied the impact of PVT treatment on this population for efficacy, safety and the impact on survival. In survival analysis Mantel-Cox and Wilcoxon-Breslow-Gehan tests were used. A P value of <0.05, was considered significant. For statistical computations the STATA 12.1 was used. RESULTS Seventy-six patients were included (76% decompensated, median MELD score 12 and Child-Pugh score 7), 47% with concomitant HCC. Fifty-one patients with PVT were treated with Vitamin-K antagonists or Low-Molecular-Weight Heparin. Patients were followed up for at least 6 months after PVT diagnosis, or until death or transplantation. PV patency after 6 months was not statistically different between patients receiving or not anticoagulation (complete-partial recanalization 27.4% of treated vs. 20% of untreated, P=0.21). Median survival was statistically worse between patients treated with anticoagulation than those untreated (10 vs. 15 months, P=0.036). Less portal hypertensive bleeding and less decompensation rates were found in treated cirrhotics vs. untreated (45.8% vs. 54.2%, P=0.003 and 78% vs. 80.9%, P=0.78, respectively). Patients with HCC had worse survival when treated vs. untreated (P=0.047). CONCLUSIONS In our cohort of cirrhotics with PVT, treatment was feasible with acceptable side effects, but without meaningful clinical benefits.
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Affiliation(s)
- Aikaterini Mantaka
- Department of Gastroenterology & Hepatology, University Hospital of Heraklion, Heraklion, Crete, Greece -
| | - Nikolaos Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Christos K Triantos
- Department of Gastroenterology, University Hospital of Patras, Patras, Greece
| | - Ulrich Thalheimer
- Department of Gastroenterology, Royal Shrewsbury Hospital, Shrewsbury, UK
| | - Gioacchino Leandro
- Department of Gastroenterology, IRCCS Saverio De Bellis Hospital, Castellana Grotte, Bari, Italy
| | - Kalliopi Zachou
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | | | - Asterios Saitis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | | | - Elias A Kouroumalis
- Department of Gastroenterology & Hepatology, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Dimitrios N Samonakis
- Department of Gastroenterology & Hepatology, University Hospital of Heraklion, Heraklion, Crete, Greece
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5
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Clinical and imaging predictors of the natural course of bland portal vein thrombus in cirrhotic patients. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 47:3724-3732. [PMID: 35943518 DOI: 10.1007/s00261-022-03626-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 07/13/2022] [Accepted: 07/15/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Portal vein thrombus (PVT) in cirrhotic patients is associated with worsening portal hypertension, leads to increased complexity of necessary interventions such as transjugular liver portosystemic shunt or liver transplantation, and is associated with worse outcomes after liver transplantation. Additionally, there are no established consensus guidelines for management of bland PVT in cirrhotic patients, which currently exists on a spectrum and is patient and provider dependent. PURPOSE The aim of this study was to determine whether there are associations between key clinical and imaging variables and bland PVT burden over time. MATERIAL AND METHODS This exploratory, retrospective, single-center study included patients who underwent two or more multiphase CT or MRI examinations between 1/1/2013 and 12/31/2019 and had a diagnosis of PVT. Three readers independently evaluated all index and follow-up examinations for PVT burden using a proposed 8-point scale and the established Yerdel score. Key clinical factors were collected from the electronic medical record. The PVT burden over time and the association of this burden with key clinical and imaging variables were assessed using logistic regression models. RESULTS 138 patients with cirrhosis and bland PVT were included in the analyses. Median age was 60 years (interquartile range 55-67; 90 men) and median follow-up time was 19.6 months. At baseline, the mean score was 2.31 (± 1.44) and at the final follow-up examination, the mean score was 2.52 (± 1.99). Baseline occlusion level was the only statistically significant association with worsening PVT burden in all four vascular territories (p-value < 0.0001). Anticoagulation status did not have a statistically significant association with change in thrombus burden in any vascular territory or cumulative thrombus burden across all territories (p-value 0.11-0.43). CONCLUSION In conclusion, our study shows that in cirrhotic patients with bland PVT, the thrombus burden did not change significantly over time and baseline thrombus burden is the only clinical factor significantly associated with increasing burden over time.
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Islam R, Kundu S, Jha SB, Rivera AP, Flores Monar GV, Islam H, Puttagunta SM, Sange I. Cirrhosis and Coagulopathy: Mechanisms of Hemostasis Changes in Liver Failure and Their Management. Cureus 2022; 14:e23785. [PMID: 35518552 PMCID: PMC9063731 DOI: 10.7759/cureus.23785] [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] [Accepted: 04/03/2022] [Indexed: 11/20/2022] Open
Abstract
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.
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7
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Gupta S, Hidalgo J, Singh B, Iyer A, Yang Y, Short A, Singh S, Bhatt H, Gupta S. Usage of Direct Acting Oral Anticoagulants in Cirrhotic and Non-Cirrhotic Portal Vein Thrombosis: A Systematic Review. Cureus 2021; 13:e16922. [PMID: 34367844 PMCID: PMC8342267 DOI: 10.7759/cureus.16922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 12/15/2022] Open
Abstract
Thrombosis of the portal vein (PVT) is generally seen in the setting of liver cirrhosis and to a lesser extent in the absence of cirrhosis. There is no clear guidance in relation to approaching treatment with anticoagulation in this condition. The professional societies and guidelines recommend treatment with traditional anticoagulation like low-molecular-weight heparin and vitamin-K antagonists in patients presenting with acute portal vein thrombosis. There is no clarity in relation to treatment in the setting of chronic PVT and in patients with cirrhosis. Also, the role of direct-acting oral anticoagulants (DOACs) that are becoming a preferred choice for anticoagulation for various other indications is not clear in the case of PVT. There are a very few studies in the medical literature that have investigated the role of DOACs in patients with PVT in different settings. Thus, we performed a systematic review of the literature to study the use of DOACs in PVT in patients with and without cirrhosis. The results of the available studies show that DOACS appears to be a promising choice for the treatment of patients with PVT. The availability of more data in the future along with better availability of the approved reversal agents for various DOACs is expected to make DOACS a preferred choice for the clinicians to treat patients with PVT.
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Affiliation(s)
- Sachin Gupta
- Hospital Medicine, Tower Health Reading Hospital, West Reading, USA
| | - Jessica Hidalgo
- Internal Medicine, San Francisco de Quito University, Quito, ECU
| | - Balraj Singh
- Hematology/Oncology, Saint Joseph's University Medical Center, Paterson, USA
| | - Aditya Iyer
- Internal Medicine, Washington Hospital Center, Washington DC, USA
| | - Yang Yang
- Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Alexandra Short
- Library Services, Tower Health Reading Hospital, West Reading, USA
| | - Sandeep Singh
- Internal Medicine, Indiana University School of Medicine, South Bend, USA
| | - Harshil Bhatt
- Internal Medicine, Indiana University School of Medicine, South Bend, USA.,Internal Medicine, Goshen Hospital, Goshen, USA
| | - Sorab Gupta
- Oncology, Bronx Care Health System, New York, USA
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8
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Moiz B, Muslim Z, Siddiqui ZF, Zafar H. Acute Mesenteric Thrombosis: A Hematologist Perspective. Clin Appl Thromb Hemost 2021; 26:1076029620932999. [PMID: 32530709 PMCID: PMC7427042 DOI: 10.1177/1076029620932999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Bushra Moiz
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
- Bushra Moiz, Department of Pathology and Laboratory Medicine, The Aga Khan University Hospital, Karachi, Pakistan.
| | | | | | - Hasnain Zafar
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
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9
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Guyot A, Lequeu JB, Dransart-Rayé O, Chevallier O, Nguyen M, Charles PE, Mouillot T, Manfredi S, Degand T. [Management of acute pancreatitis. A literature review]. Rev Med Interne 2021; 42:625-632. [PMID: 33676780 DOI: 10.1016/j.revmed.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 12/02/2020] [Accepted: 01/09/2021] [Indexed: 12/07/2022]
Abstract
The management of acute pancreatitis is now fairly codified, with specific recommendations developed by expert groups. These recommendations deal in particular with the minimum initial assessment, recognized severity scores, initial medical management with hyperhydration, preventive anticoagulation, early refeeding, delays in imaging and management of complications. In this work, we have tried to bring together the various recommendations, articles and studies dealing with this subject, based more particularly on European recommendations, in order to guide the management of acute pancreatitis in current practice.
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Affiliation(s)
- A Guyot
- Service d'hépato-gastro-entérologie, CHU de Dijon F.-Mitterrand Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France.
| | - J B Lequeu
- Chirurgie viscérale, digestive et endocrinienne, CHU de Dijon, Dijon, France.
| | - O Dransart-Rayé
- Département d'anesthésie réanimation, CHU de Dijon, Dijon, France.
| | - O Chevallier
- Département de radiologie diagnostique et thérapeutique, CHU de Dijon, Dijon, France.
| | - M Nguyen
- Département d'anesthésie réanimation, CHU de Dijon, Dijon, France.
| | - P E Charles
- Médecine intensive réanimation, CHU de Dijon, Dijon, France.
| | - T Mouillot
- Service d'hépato-gastro-entérologie, CHU de Dijon F.-Mitterrand Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France.
| | - S Manfredi
- Service d'hépato-gastro-entérologie, CHU de Dijon F.-Mitterrand Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France.
| | - T Degand
- Service d'hépato-gastro-entérologie, CHU de Dijon F.-Mitterrand Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France.
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10
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Toyoda J, Morioka D, Horii N, Nakayama G, Oyama N, Asano F, Izumisawa Y, Miura M, Sato Y, Endo I. Treatment of acute exacerbation of liver-cirrhosis-associated portal vein thrombosis with direct-acting oral anticoagulant, edoxaban, used as an initial treatment in the early postoperative period after abdominal surgery: a case report. J Med Case Rep 2021; 15:52. [PMID: 33563326 PMCID: PMC7874483 DOI: 10.1186/s13256-020-02651-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 12/25/2020] [Indexed: 12/15/2022] Open
Abstract
Background Cirrhosis-associated portal vein thrombosis (CA-PVT) has been reportedly observed in 5–30% of cirrhotic patients. Moreover, the acute exacerbation of CA-PVT is likely to occur after certain situations, such as a status after abdominal surgery. Safety and efficacy of the direct-acting oral anticoagulant (DOAC) used for cirrhotic patients have been being confirmed. However, use of the DOAC as an initial treatment for CA-PVT appears still challenging especially in the early postoperative period after major surgery in terms of unestablished efficacy and safety in such occasion. Case presentation We herein report a case of the acute exacerbation of CA-PVT in the early postoperative period after abdominal surgery, which was successfully treated with DOAC, edoxaban used as an initial treatment. The patient was a 79-year-old Japanese male with alcoholic cirrhosis. The patient suffered choledocholithiasis and had a mural chronic CA-PVT extending from the superior mesenteric vein to the portal trunk. He underwent open cholecystectomy and choledochotomy. Early postoperative clinical course was uneventful except for abdominal distension due to ascites diagnosed on postoperative day (POD)7 when hospital discharge was planned. Contrast enhancement computed tomography (CE-CT) taken on POD 7 revealed the exacerbation of the CA-PVT. Despite recommendation for extension of hospital admission with low molecular weight heparin treatment, the patient strongly hoped to be discharged. Unwillingly, we selected DOAC, edoxaban, as an initial treatment, which was commenced the day after discharge (POD8). As a result, the remarkable improvement of the exacerbated CA-PVT was confirmed by the CE-CT taken on POD21. Any bleeding complications were not observed. Although a slight residue of the CA-PVT remains, the patient is currently doing well 4 years after surgery and is still receiving edoxaban. Any adverse effects of edoxaban have not been observed for 4 years. Conclusions A case of successful treatment of the acute exacerbation of CA-PVT with edoxaban was reported. Moreover, edoxaban has been safely administered in a cirrhotic patient for 4 years. The findings obtained from the present case suggest that DOAC can be used as an initial treatment for CA-PVT even in early postoperative period after major abdominal surgery.
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Affiliation(s)
- Junya Toyoda
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Daisuke Morioka
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan. .,Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan.
| | - Nobutoshi Horii
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Gakuryu Nakayama
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Norio Oyama
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Fumio Asano
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Yusuke Izumisawa
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Masaru Miura
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan
| | - Yoshiki Sato
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
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11
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Nicoară-Farcău O, Soy G, Magaz M, Baiges A, Turon F, Garcia-Criado A, Barrufet M, Burrel M, Hernández-Gea V, García-Pagán JC. New Insights into the Pathogenesis, Risk Factors, and Treatment of Portal Vein Thrombosis in Patients with Cirrhosis. Semin Thromb Hemost 2020; 46:673-681. [PMID: 32820481 DOI: 10.1055/s-0040-1715473] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis (PVT) is a frequent event in patients with cirrhosis regardless of etiology. Notwithstanding the commonality of the problem, the pathophysiology and risk factors for PVT in cirrhosis are largely unknown. The clinical impact of PVT in the natural history of cirrhosis is unclear, indications for PVT treatment are not well defined, and treatment recommendations are based on experts' opinion and consensus only. Therefore, this review aims to summarize current knowledge of mechanisms and risk factors for PVT development and assess the current evidence of PVT management, with a special focus on strategies of anticoagulation and transjugular intrahepatic portosystemic shunt placement.
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Affiliation(s)
- Oana Nicoară-Farcău
- Department of Hepatology, Regional Institute of Gastroenterology and Hepatology "Octavian Fodor," "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Guillem Soy
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Marta Magaz
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Anna Baiges
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Fanny Turon
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Angeles Garcia-Criado
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver).,Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Marta Barrufet
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver).,Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Marta Burrel
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver).,Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Virginia Hernández-Gea
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Juan Carlos García-Pagán
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
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12
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Abstract
Pylephlebitis is a rare condition that is characterized by an infected thrombus of the portal vein system and was traditionally associated with a high mortality rate prior to the introduction of antibiotics. This report details a 77-year-old Chinese male found to have a splenic vein thrombosis, Parvimonas micra bacteremia, and a polymicrobial splenic abscess. The patient was treated with abscess drainage and a 6 week course of intravenous antibiotics, and a direct oral anticoagulant, apixaban 2.5 mg twice daily. To our knowledge, this is the second documented case of pylephlebitis treated with apixaban. Here, we summarize our experience treating this case of pylephlebitis and briefly report on the existing body of literature.
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Affiliation(s)
- Graham R Hale
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Leon Alan Sakkal
- Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA
| | - Taki Galanis
- Jefferson Vascular Center, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
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13
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Faccia M, Ainora ME, Ponziani FR, Riccardi L, Garcovich M, Gasbarrini A, Pompili M, Zocco MA. Portal vein thrombosis in cirrhosis: Why a well-known complication is still matter of debate. World J Gastroenterol 2019; 25:4437-4451. [PMID: 31496623 PMCID: PMC6710174 DOI: 10.3748/wjg.v25.i31.4437] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/08/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) represents a well-known complication during the natural course of liver cirrhosis (LC), ranging from asymptomatic cases to life-threating conditions related to portal hypertension and hepatic decompensation. Portal flow stasis, complex acquired hypercoagulable disorders and exogenous factors leading to endothelial dysfunction have emerged as key factors for PVT development. However, PVT occurrence remains unpredictable and many issues regarding its natural history, prognostic significance and treatment are still elusive. In particular although spontaneous resolution or disease stability occur in most cases of PVT, factors predisposing to disease progression or recurrence after spontaneous recanalization are not clarified as yet. Moreover, PVT impact on LC outcome is still debated, as PVT may represent itself a consequence of liver fibrosis and hepatic dysfunction progression. Anticoagulation and transjugular intrahepatic portosystemic shunt are considered safe and effective in this setting and are recommended in selected cases, even if the safer therapeutic option and the optimal therapy duration are still unknown. Nevertheless, their impact on mortality rates should be addressed more extensively. In this review we present the most debated questions regarding PVT, whose answers should come from prospective cohort studies and large sample-size randomized trials.
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Affiliation(s)
- Mariella Faccia
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Maria Elena Ainora
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Francesca Romana Ponziani
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Laura Riccardi
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Matteo Garcovich
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Maurizio Pompili
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Maria Assunta Zocco
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
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14
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Hernández-Gea V, De Gottardi A, Leebeek FWG, Rautou PE, Salem R, Garcia-Pagan JC. Current knowledge in pathophysiology and management of Budd-Chiari syndrome and non-cirrhotic non-tumoral splanchnic vein thrombosis. J Hepatol 2019; 71:175-199. [PMID: 30822449 DOI: 10.1016/j.jhep.2019.02.015] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 12/11/2022]
Abstract
Budd-Chiari syndrome and non-cirrhotic non-tumoral portal vein thrombosis are 2 rare disorders, with several similarities that are categorized under the term splanchnic vein thrombosis. Both disorders are frequently associated with an underlying prothrombotic disorder. They can cause severe portal hypertension and usually affect young patients, negatively influencing life expectancy when the diagnosis and treatment are not performed at an early stage. Yet, they have specific features that require individual consideration. The current review will focus on the available knowledge on pathophysiology, diagnosis and management of both entities.
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Affiliation(s)
- Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, European Reference Network for Rare Vascular Liver Diseases, Universitat de Barcelona, Spain
| | - Andrea De Gottardi
- Hepatology, University Clinic of Visceral Medicine and Surgery, Inselspital, and Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France; Inserm, UMR-970, Paris Cardiovascular Research Center, PARCC, Paris, France
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, European Reference Network for Rare Vascular Liver Diseases, Universitat de Barcelona, Spain.
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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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Anticoagulation in Patients with Liver Cirrhosis (Literature Review). ACTA BIOMEDICA SCIENTIFICA 2019. [DOI: 10.29413/abs.2019-4.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Liver cirrhosis is accompanied by complex hemostatic disorders with an increase in the risk of both hemorrhagic and thrombotic complications. Reduced coagulation protein synthesis, such as factors II, VII, IX, X and thrombocytopenia are associated with an increased risk of bleeding. Reducing the synthesis of such anticoagulants as protein C, protein S, antithrombin III is accompanied by increased generation of thrombin, which leads to procoagulant status, increased risk of venous thrombosis, pulmonary embolism, and portal vein thrombosis. Activation of the coagulation cascade increases the risk of thrombosis, and also plays an important role in liver damage, contributing to the progression of fibrosis. Cirrhosis increases the risk of thromboembolic complications of atrial fibrillation.Anticoagulants are necessary for the prevention of thrombosis and thromboembolic complications. However, there are no large prospective studies. There is insufficient data on the safety of anticoagulant therapy in cirrhosis. There are difficulties in monitoring anticoagulation in the application of vitamin K antagonists and low molecular weight heparins.The review presents the available data on the use of warfarin, unfractionated heparin, low molecular weight heparins and direct oral anticoagulants in patients with liver cirrhosis, indicating the need for prevention of venous thrombosis in patients with risk factors, the possibility of preventing decompensation of cirrhosis, reducing the frequency of cardioembolic strokes in patients with atrial fibrillation.
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17
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Steuber TD, Howard ML, Nisly SA. Direct Oral Anticoagulants in Chronic Liver Disease. Ann Pharmacother 2019; 53:1042-1049. [PMID: 30947523 DOI: 10.1177/1060028019841582] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective: To review the use of direct oral anticoagulants (DOACs) in patients with chronic liver disease (CLD). Data Sources: A MEDLINE literature search was performed from 1964 through February 2019 using the following search terms: cirrhosis, chronic liver disease, direct oral anticoagulant, and the individual DOACs. Study Selection and Data Extraction: All English-language human trials and reports that examined DOACs for treatment or prevention of venous thromboembolic (VTE) events in patients with CLD were included. Data Synthesis: A total of 6 clinical trials examining the use of DOACs in patients with CLD were identified. All DOACs have been utilized in patients with CLD, with the exception of betrixaban, for prevention of stroke in atrial fibrillation or treatment of VTE (except for treatment of pulmonary embolism). The studies primarily evaluated patients with mild to moderate liver disease (Child-Turcotte-Pugh class A and B). The DOACs had similar rates of bleeding compared with traditional anticoagulants. Relevance to Patient Care and Clinical Practice: This review evaluates and summarizes the available evidence on DOACs in the setting of CLD. These agents may be more appealing in this population because monitoring or administration may be difficult with traditional anticoagulants (warfarin or low-molecular-weight heparins). Conclusion: Early data suggest that DOACs may be safe in patients with mild to moderate CLD. Should a DOAC be selected as an alternative to traditional anticoagulants, more frequent monitoring should be used because hepatotoxicity may be a concern. Larger clinical trials are needed to address efficacy outcomes as well as differences among individual DOACs in this population.
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Affiliation(s)
- Taylor D Steuber
- 1 Auburn University Harrison School of Pharmacy, Huntsville, AL, USA
| | - Meredith L Howard
- 2 University of North Texas System College of Pharmacy, Fort Worth, TX, USA
| | - Sarah A Nisly
- 3 Wingate University School of Pharmacy, Wingate, NC, USA
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18
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Direct Oral Anticoagulants in Cirrhotic Patients: Current Evidence and Clinical Observations. Can J Gastroenterol Hepatol 2019; 2019:4383269. [PMID: 30792971 PMCID: PMC6354142 DOI: 10.1155/2019/4383269] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 12/17/2018] [Accepted: 12/26/2018] [Indexed: 02/07/2023] Open
Abstract
The introduction of Direct Oral Anticoagulants (DOACs) to the pharmaceutical market provided patients and clinicians with novel convenient and safe options of anticoagulation. The use of this class of medications is currently limited to venous thromboembolic therapy and prophylaxis, in addition to stroke prophylaxis in patients with nonvalvular atrial fibrillation. Despite their altered hemostasis, patients with cirrhosis are thought to be in a procoagulant state and thus prone to thrombus formation. Patients with cirrhosis might benefit from the convenience of DOACs; however, the medical literature includes limited data on the efficacy and safety of DOACs in this special patient population. The aim of this review is to summarize the current evidence for anticoagulation options in patients with cirrhosis and their safety profile.
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19
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Abstract
BACKGROUND AND OBJECTIVE Portal vein thrombosis (PVT) is a common complication in cirrhosis, and when complete, it increases morbidity and mortality in liver transplant candidates. The aim of the study was to assess the hemostatic status, as well as clinical characteristics of thrombus and patients, as predictors of therapeutic efficacy of anticoagulation for the treatment of PVT in cirrhotics. PATIENTS AND METHODS Patients with cirrhosis consecutively treated for PVT with enoxaparin were enrolled. All patients underwent evaluation of coagulation status and thrombophilia screening. Thrombus characteristics and extension were evaluated at baseline and during follow-up. Anticoagulation was continued until recanalization or up to 12 months. Variables correlated with the response to anticoagulation were used to create a predictive score that was validated in an external multicenter cohort. RESULTS A total of 65 patients were included and had partial PVT in most cases (72%). Treatment with enoxaparin resulted in an overall response rate of 66% (43/65) after a median time of 4.4 months and 76% (33/43) within the first 6 months. At multivariate analysis, efficacy of anticoagulation correlated with the severity of liver disease, complete verus partial PVT, age of the thrombus, and time interval from treatment start (<6 months). The areas under the curve of the statistical model for predicting the response to anticoagulation were 0.84 and 0.76 for the training (n=65) and validation (n=60) cohorts, respectively. CONCLUSION Early diagnosis and early treatment are key factors for the successful management of PVT in cirrhosis, so that screening of PVT and prompt start of anticoagulant treatment should be mandatory.
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20
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Intagliata NM, Argo CK, Stine JG, Lisman T, Caldwell SH, Violi F. Concepts and Controversies in Haemostasis and Thrombosis Associated with Liver Disease: Proceedings of the 7th International Coagulation in Liver Disease Conference. Thromb Haemost 2018; 118:1491-1506. [PMID: 30060258 PMCID: PMC6202935 DOI: 10.1055/s-0038-1666861] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/17/2018] [Indexed: 12/12/2022]
Affiliation(s)
- N. M. Intagliata
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - C. K. Argo
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - J. G. Stine
- Department of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - T. Lisman
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - S. H. Caldwell
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - F. Violi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
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21
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Pant A, Kopec AK, Luyendyk JP. Role of the blood coagulation cascade in hepatic fibrosis. Am J Physiol Gastrointest Liver Physiol 2018; 315:G171-G176. [PMID: 29723040 PMCID: PMC6139645 DOI: 10.1152/ajpgi.00402.2017] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 04/19/2018] [Accepted: 04/24/2018] [Indexed: 02/07/2023]
Abstract
Liver is the primary source of numerous proteins that are critical for normal function of the blood coagulation cascade. Because of this, diseases of the liver, particularly when affiliated with severe complications like cirrhosis, are associated with abnormalities of blood clotting. Although conventional interpretation has inferred cirrhosis as a disorder of uniform bleeding risk, it is now increasingly appreciated as a disease wherein the coagulation cascade is precariously rebalanced. Moreover, prothrombotic risk factors are also associated with a more rapid progression of fibrosis in humans, suggesting that coagulation proteases participate in disease pathogenesis. Indeed, strong evidence drawn from experimental animal studies indicates that components of the coagulation cascade, particularly coagulation factor Xa and thrombin, drive profibrogenic events, leading to hepatic fibrosis. Here, we concisely review the evidence supporting a pathologic role for coagulation in the development of liver fibrosis and the potential mechanisms involved. Further, we highlight how studies in experimental animals may shed light on emerging clinical evidence, suggesting that beneficial effects of anticoagulation could extend beyond preventing thrombotic complications to include reducing pathologies like fibrosis.
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Affiliation(s)
- Asmita Pant
- Department of Pathobiology and Diagnostic Investigation, Michigan State University , East Lansing, Michigan
- Institute for Integrative Toxicology, Michigan State University , East Lansing, Michigan
| | - Anna K Kopec
- Department of Pathobiology and Diagnostic Investigation, Michigan State University , East Lansing, Michigan
- Institute for Integrative Toxicology, Michigan State University , East Lansing, Michigan
| | - James P Luyendyk
- Department of Pathobiology and Diagnostic Investigation, Michigan State University , East Lansing, Michigan
- Institute for Integrative Toxicology, Michigan State University , East Lansing, Michigan
- Department of Pharmacology and Toxicology, Michigan State University , East Lansing, Michigan
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22
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Direct oral anticoagulants and cirrhosis: More evidence still needed for efficacy and safety in portal vein thrombosis. Vascul Pharmacol 2018; 113:92-93. [PMID: 29890295 DOI: 10.1016/j.vph.2018.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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23
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Newer Oral Anticoagulants in the Treatment of Acute Portal Vein Thrombosis in Patients with and without Cirrhosis. Int J Hepatol 2018; 2018:8432781. [PMID: 29973997 PMCID: PMC6008786 DOI: 10.1155/2018/8432781] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 04/30/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Newer oral anticoagulants (NOACs) are being utilized increasingly for the treatment of venous thromboembolism (VTE). NOAC use is the standard of care for stroke prophylaxis in nonvalvular atrial fibrillation and treatment of acute VTE involving extremities and pulmonary embolism. In contrast, most guidelines in the literature support the treatment of acute portal vein thrombosis (PVT) with low molecular weight heparin (LMWH) and vitamin K antagonists (VKA). Literature evaluating NOAC use in the treatment of acute portal vein thrombosis is sparse. This review focuses on the safety and efficacy of the use of NOACs in the treatment of acute PVT in patients, with or without concomitant cirrhosis, based on the most recent data available in the current literature. METHODS A systematic review was conducted through a series of advanced searches in the following medical databases: PubMed, BioMed Central, Cochrane, and Google Scholar. Keywords utilized were as follows: NOAC, DOAC (direct oral anticoagulants), portal vein thrombosis, rivaroxaban, apixaban, dabigatran, and edoxaban. Articles related to newer anticoagulant use in patients with portal vein thrombosis were included. RESULTS The adverse events, including bleeding events (major and minor) and the failure of anticoagulation (propagation of thrombus or recurrence of PVT), are similar between the NOACs and traditional anticoagulants for the treatment of acute PVT, irrespective of the presence of cirrhosis. CONCLUSIONS Newer oral anticoagulants are safe and efficacious alternatives to traditional anticoagulation with low molecular weight heparin and vitamin K antagonists in the treatment of acute portal vein thrombosis with or without cirrhosis.
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24
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Timing of Anticoagulation for Portal Vein Thrombosis in Liver Cirrhosis: An Italian Internist's Perspective. J Transl Int Med 2018; 6:6-10. [PMID: 29607297 DOI: 10.2478/jtim-2018-0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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25
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Mantaka A, Augoustaki A, Kouroumalis EA, Samonakis DN. Portal vein thrombosis in cirrhosis: diagnosis, natural history, and therapeutic challenges. Ann Gastroenterol 2018; 31:315-329. [PMID: 29720857 PMCID: PMC5924854 DOI: 10.20524/aog.2018.0245] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/26/2017] [Indexed: 12/13/2022] Open
Abstract
Portal vein thrombosis (PVT) is a frequent complication in cirrhosis and its prevalence increases with disease severity. Several factors are involved in the development and progression of PVT. The challenge for the management of PVT is the precise evaluation of the bleeding risk as opposed to life-threatening extension of thrombosis. Nevertheless, the impact on the progression and outcome of liver disease is unclear. A critical evaluation of the available data discloses that treating PVT in cirrhotics is safe and effective. However, there are open issues, such as which anticoagulant could represent a safer therapeutic option, and when and for how long this treatment should be administered to cirrhotic patients with PVT.
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Affiliation(s)
- Aikaterini Mantaka
- Department of Gastroenterology and Hepatology, University Hospital of Crete, Heraklion, Crete, Greece
| | - Aikaterini Augoustaki
- Department of Gastroenterology and Hepatology, University Hospital of Crete, Heraklion, Crete, Greece
| | - Elias A Kouroumalis
- Department of Gastroenterology and Hepatology, University Hospital of Crete, Heraklion, Crete, Greece
| | - Dimitrios N Samonakis
- Department of Gastroenterology and Hepatology, University Hospital of Crete, Heraklion, Crete, Greece
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26
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Nagaoki Y, Aikata H, Daijyo K, Teraoka Y, Shinohara F, Nakamura Y, Hatooka M, Morio K, Nakahara T, Kawaoka T, Tsuge M, Hiramatsu A, Imamura M, Kawakami Y, Ochi H, Chayama K. Efficacy and safety of edoxaban for treatment of portal vein thrombosis following danaparoid sodium in patients with liver cirrhosis. Hepatol Res 2018; 48:51-58. [PMID: 28342265 DOI: 10.1111/hepr.12895] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/09/2017] [Accepted: 03/17/2017] [Indexed: 12/14/2022]
Abstract
AIM To compare the efficacy and safety of edoxaban and warfarin for treatment of portal vein thrombosis (PVT) following danaparoid sodium in patients with liver cirrhosis. METHODS Fifty cirrhotic patients with PVT treated initially for 2 weeks with danaparoid sodium were enrolled in this retrospective cohort study. Treatment was later switched to either edoxaban (n = 20) or warfarin (n = 30). We compared the efficacy and safety of edoxaban and warfarin for up to 6 months. The PVT volume was measured by dynamic computed tomography before treatment, at 2 weeks, and at 1, 3, and 6 months. RESULTS There were no significant differences in the clinical characteristics of patients in the two groups. Treatment with edoxaban reduced the volume of PVT from 1.42 cm3 at 2 weeks to 0.42 cm3 at 6 months, and prevented exacerbation of PVT at 6 months after treatment with danaparoid sodium (P = 0.016). In contrast, treatment with warfarin resulted in increased PVT volume from 1.73 cm3 at 2 weeks to 2.85 cm3 at 6 months, despite the control of the international normalized ratio in 57% of the patients (P = 0.005). Multivariate regression analysis identified edoxaban therapy as the single significant and independent determinant of PVT reduction at 6 months (P = 0.0014, hazard ratio 6.400). Clinically significant gastrointestinal bleeding was encountered in 3 of 20 (15%) patients of the edoxaban group and 2 of 30 (7%) of the warfarin group (P = 0.335). CONCLUSION Edoxaban following danaparoid sodium is an effective anticoagulant and could be potentially considered as one of the treatment options for PVT in cirrhotic patients.
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Affiliation(s)
- Yuko Nagaoki
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Aikata
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Liver Research Project Center, Hiroshima University, Hiroshima, Japan
| | - Kana Daijyo
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Yuji Teraoka
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Fumi Shinohara
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Yuki Nakamura
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Masahiro Hatooka
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Kei Morio
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Takashi Nakahara
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Liver Research Project Center, Hiroshima University, Hiroshima, Japan
| | - Tomokazu Kawaoka
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Liver Research Project Center, Hiroshima University, Hiroshima, Japan
| | - Masataka Tsuge
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Liver Research Project Center, Hiroshima University, Hiroshima, Japan.,Natural Science Center for Basic Research and Development, Hiroshima University, Hiroshima, Japan
| | - Akira Hiramatsu
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Liver Research Project Center, Hiroshima University, Hiroshima, Japan
| | - Michio Imamura
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Liver Research Project Center, Hiroshima University, Hiroshima, Japan
| | - Yoshiiku Kawakami
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Liver Research Project Center, Hiroshima University, Hiroshima, Japan
| | - Hidenori Ochi
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Liver Research Project Center, Hiroshima University, Hiroshima, Japan.,Laboratory for Digestive Diseases, RIKEN Center for Integrative Medical Sciences, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.,Liver Research Project Center, Hiroshima University, Hiroshima, Japan.,Laboratory for Digestive Diseases, RIKEN Center for Integrative Medical Sciences, Hiroshima, Japan
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27
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Riva N, Ageno W. Approach to thrombosis at unusual sites: Splanchnic and cerebral vein thrombosis. Vasc Med 2017; 22:529-540. [PMID: 29202678 DOI: 10.1177/1358863x17734057] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Nicoletta Riva
- 1 Department of Pathology, University of Malta, Msida, Malta
| | - Walter Ageno
- 2 Department of Medicine and Surgery, University of Insubria, Varese, Italy
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28
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Klinger C, Riecken B, Schmidt A, De Gottardi A, Meier B, Bosch J, Caca K. Transjugular local thrombolysis with/without TIPS in patients with acute non-cirrhotic, non-malignant portal vein thrombosis. Dig Liver Dis 2017; 49:1345-1352. [PMID: 28733177 DOI: 10.1016/j.dld.2017.05.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/05/2017] [Accepted: 05/21/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Therapeutic anticoagulation is the standard treatment in patients with acute non-cirrhotic portal vein thrombosis (PVT). In critically ill patients, anticoagulation only may not suffice to achive rapid and stable recanalization. This study evaluates efficacy and safety of transjugular interventional therapy in acute non-cirrhotic PVT. METHODS This retrospective study includes 17 consecutive patients with acute noncirrhotic, non-malignant PVT. Main indication for interventional therapy was imminent intestinal infarction (n=10). Treatment consisted of a combination of transjugular thrombectomy, local fibrinolysis and - depending on thrombus resolution - transjugular intrahepatic portosystemic shunt. RESULTS Recanalization was successful in 94.1%. One- and two-year secondary PV patency rates were 88.2%. Major complications (n=3) resolved spontaneously in all but one patient (heparin induced thrombocytopenia type 2 with intestinal infarction). Symptoms improved in all patients. However, segmental bowel resection had to be performed in two (11.8%). During a median follow-up of 28.6 months, no patient experienced portal hypertensive complications. Presence of JAK2 V617F mutation predicted both short-term and long-term technical success. CONCLUSIONS Transjugular recanalization is safe and effective in patients with acute non-cirrhotic, non-malignant PVT. It should be considered especially in patients with imminent bowel infarction and low likelihood of recanalization following therapeutic anticoagulation. Patients with JAK2 mutation ought to be followed meticulously.
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Affiliation(s)
- Christoph Klinger
- Department of Gastroenterology, Hepatology and Oncology, Hospital of Ludwigsburg, Germany
| | - Bettina Riecken
- Department of Gastroenterology, Hepatology and Oncology, Hospital of Ludwigsburg, Germany
| | - Arthur Schmidt
- Department of Gastroenterology, Hepatology and Oncology, Hospital of Ludwigsburg, Germany
| | | | - Benjamin Meier
- Department of Gastroenterology, Hepatology and Oncology, Hospital of Ludwigsburg, Germany
| | - Jaime Bosch
- Hepatology, Inselspital, University of Berne, Switzerland; Hepatic Hemodynamic Laboratory, Liver Unit Hospital Cliníc, IDIBAPS and Ciberehd, Barcelona, Spain
| | - Karel Caca
- Department of Gastroenterology, Hepatology and Oncology, Hospital of Ludwigsburg, Germany; Hepatology, Inselspital, University of Berne, Switzerland.
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29
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Martín-Llahí M, Albillos A, Bañares R, Berzigotti A, García-Criado MÁ, Genescà J, Hernández-Gea V, Llop-Herrera E, Masnou-Ridaura H, Mateo J, Navascués CA, Puente Á, Romero-Gutiérrez M, Simón-Talero M, Téllez L, Turon F, Villanueva C, Zarrabeitia R, García-Pagán JC. Enfermedades vasculares del hígado. Guías Clínicas de la Sociedad Catalana de Digestología y de la Asociación Española para el Estudio del Hígado. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 40:538-580. [DOI: 10.1016/j.gastrohep.2017.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 03/29/2017] [Indexed: 12/11/2022]
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30
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Use of Rivaroxaban for Mesenteric Vein Thrombosis Secondary to Diverticulitis: A Case Report. Am J Ther 2017; 24:e629-e630. [DOI: 10.1097/mjt.0000000000000512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Dhar A, Mullish BH, Thursz MR. Anticoagulation in chronic liver disease. J Hepatol 2017; 66:1313-1326. [PMID: 28088580 DOI: 10.1016/j.jhep.2017.01.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 01/03/2017] [Accepted: 01/04/2017] [Indexed: 02/06/2023]
Abstract
In this Grand Round presentation, the case of a man with decompensated liver disease is described. He subsequently developed a fatal pulmonary embolism, which may not have occurred if he had been prescribed prophylactic anticoagulation to prevent venous thromboembolic disease. The burden of thrombotic disease in those with chronic liver disease is discussed, before a more detailed analysis of the current evidence, safety data, and clinical dilemmas regarding the use of anticoagulation in patients with chronic liver disease. Finally, the future directions within this field are explored.
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Affiliation(s)
- Ameet Dhar
- Division of Digestive Diseases, Department of Surgery and Cancer, St Mary's Hospital Campus, Imperial College London, London, UK
| | - Benjamin H Mullish
- Division of Digestive Diseases, Department of Surgery and Cancer, St Mary's Hospital Campus, Imperial College London, London, UK
| | - Mark R Thursz
- Division of Digestive Diseases, Department of Surgery and Cancer, St Mary's Hospital Campus, Imperial College London, London, UK.
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32
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De Gottardi A, Trebicka J, Klinger C, Plessier A, Seijo S, Terziroli B, Magenta L, Semela D, Buscarini E, Langlet P, Görtzen J, Puente A, Müllhaupt B, Navascuès C, Nery F, Deltenre P, Turon F, Engelmann C, Arya R, Caca K, Peck-Radosavljevic M, Leebeek FWG, Valla D, Garcia-Pagan JC. Antithrombotic treatment with direct-acting oral anticoagulants in patients with splanchnic vein thrombosis and cirrhosis. Liver Int 2017; 37:694-699. [PMID: 27778440 DOI: 10.1111/liv.13285] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 10/18/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Direct-acting oral anticoagulants (DOACs) are used in patients with splanchnic vein thrombosis (SVT) and cirrhosis, but evidence for safety and efficacy in this setting is limited. Our aim was to identify indications and reasons for starting or switching to DOACs and to report adverse effects, complications and short-term outcome. METHODS Data collection including demographic information, laboratory values, treatment and complications through the Vascular Liver Disease Interest Group Consortium. RESULTS Forty-five centres (90%) of the consortium completed the initial eCRF. We report here a series of 94 patients from 17 centres. Thirty-six patients (38%) had cirrhosis. Child-Pugh score was 6 (range 5-8), and MELD score 10.2 (range 6-19). Indications for anticoagulation were splanchnic vein thrombosis (75%), deep vein thrombosis (5%), atrial fibrillation (14%) and others (6%). DOACs used were rivaroxaban (83%), dabigatran (11%) and apixaban (6%). Patients were followed up for a median duration of 15 months (cirrhotic) and 26.5 months (non-cirrhotic). Adverse events occurred in 17% of patients and included one case of recurrent portal vein thrombosis and five cases of bleeding. Treatment with DOACs was stopped in three cases. The major reasons for choosing DOACs were no need for monitoring or inadequacy of INR to guide anticoagulation in cirrhotic patients. Renal and liver function did not change during treatment. CONCLUSIONS A consistent number of patients with SVT and/or cirrhosis are currently treated with DOACs, which seem to be effective and safe. These data provide a basis for performing randomized clinical trials of DOACs vs. low molecular weight heparin or vitamin K antagonists.
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Affiliation(s)
- Andrea De Gottardi
- Hepatology, Department of Clinical Research and Clinic of Visceral Surgery and Medicine, Inselspital, University of Berne, Berne, Switzerland
| | | | | | | | | | | | | | - David Semela
- Kantonsspital St. Gallen, St. Gallen, Switzerland
| | | | | | | | - Angela Puente
- HUMV and Investigation Institute Marques de Valdecilla, Santander, Spain
| | | | | | | | | | - Fanny Turon
- Hospital Clinic, IDIBAPS and CIBERehd, Barcelona, Spain
| | | | | | - Karel Caca
- Klinikum Ludwigsburg, Ludwigsburg, Germany
| | | | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
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33
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Nery F, Valadares D, Morais S, Gomes MT, De Gottardi A. Efficacy and Safety of Direct-Acting Oral Anticoagulants Use in Acute Portal Vein Thrombosis Unrelated to Cirrhosis. Gastroenterology Res 2017; 10:141-143. [PMID: 28496539 PMCID: PMC5412551 DOI: 10.14740/gr806w] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2017] [Indexed: 12/13/2022] Open
Abstract
In acute portal vein thrombosis (APVT) unrelated to cirrhosis, anticoagulant therapy is classically started with low molecular weight heparin or vitamin K antagonists. New direct-acting oral anticoagulants (DOACs) are used in the treatment of venous thrombosis outside the splanchnic vascular bed, but not in the latter. We report a young female with APVT occurring in a non-cirrhotic liver linked to heterozygosity of factor V-Leiden and prothrombin G20210A gene mutations. Rivaroxaban was started, with total recanalization of the left and partial recanalization of the right portal vein branches, without complications. New DOACs do not need daily subcutaneous injections nor routinely blood coagulation control tests, making its use attractive, eventually increasing patient’s compliance. If proved to be safe and effective in the future studies, its use may be extended to PVT treatment. This case shows that rivaroxaban was safe, not only prevented the extension of thrombosis in the portal tract, but also resolved PVT, at least partially.
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Affiliation(s)
- Filipe Nery
- Servico de Cuidados Intensivos - Unidade Intermedia Medica, Centro Hospitalar do Porto, Hospital Sto Antonio, Porto, Portugal.,EpiUnit - Instituto de Saude Publica da Universidade do Porto, Porto, Portugal.,Instituto de Ciencias Biomedicas de Abel Salazar - UP, Porto, Portugal
| | - Diana Valadares
- Servico de Cuidados Intensivos - Unidade Intermedia Medica, Centro Hospitalar do Porto, Hospital Sto Antonio, Porto, Portugal.,Instituto de Ciencias Biomedicas de Abel Salazar - UP, Porto, Portugal
| | - Sara Morais
- Servico de Hematologia - Centro Hospitalar do Porto, Hospital Sto Antonio, Porto, Portugal
| | - Manuel Teixeira Gomes
- Instituto de Ciencias Biomedicas de Abel Salazar - UP, Porto, Portugal.,Servico de Radiologia, Centro Hospitalar do Porto, Hospital Sto Antonio, Porto, Portugal
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34
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Klute K, DeFilippis EM, Shillingford K, Chapin J, DeSancho MT. Clinical presentations, risk factors, treatment and outcomes in patients with splanchnic vein thrombosis: a single-center experience. J Thromb Thrombolysis 2017; 42:267-71. [PMID: 26831481 DOI: 10.1007/s11239-016-1337-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Splanchnic vein thrombosis (SVT) is an uncommon form of venous thrombosis. Management can be challenging due to underlying conditions, increased bleeding risk, and lack of evidence from clinical trials. We sought to characterize the presentation and management of patients with SVT at a large tertiary hospital. A total of 43 patients' electronic medical records were reviewed. Median age at diagnosis was 43 (18-71). Sixteen patients had isolated portal vein thrombosis (37.2 %), and 16 (37.2 %) had thrombosis involving multiple splanchnic veins. Abdominal pain was the most common clinical presentation (67.4 %). Thrombophilia was present in 18 patients (41.9 %), nine had underlying liver disease (20.9 %) and seven had inflammatory bowel disease (16.3 %). Thirty-nine (90.7 %) patients were treated with anticoagulation, and 11(25.6 %) of these patients underwent interventional procedures. Thirty (69.8 %) patients remained on indefinite anticoagulation. Results of follow-up imaging at least 1 month after diagnosis were available for 29 patients; imaging showed chronic, stable thrombosis in 14 patients (48.3 %), resolution of thrombosis in 13 patients (44.8 %) and asymptomatic progression in two patients (6.9 %). Recurrent thrombosis occurred in four patients (9.3 %). Major bleeding occurred in eight patients who received anticoagulation (18.6 %), including fatal subdural hematoma in one patient. In this cohort of patients managed by hematologists and gastroenterologists, the majority of patients were treated with anticoagulation. Interventional procedures were higher than in previously reported series. Our study strongly supports the interdisciplinary management of splanchnic venous thrombosis.
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Affiliation(s)
- Kelsey Klute
- Division of Hematology and Medical Oncology, Weill-Cornell Medical College, 1305 York Avenue 7th Floor, New York, NY, 10021, USA
| | | | | | - John Chapin
- Division of Hematology and Medical Oncology, Weill-Cornell Medical College, 1305 York Avenue 7th Floor, New York, NY, 10021, USA
| | - Maria T DeSancho
- Division of Hematology and Medical Oncology, Weill-Cornell Medical College, 1305 York Avenue 7th Floor, New York, NY, 10021, USA.
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35
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Raschi E, Bianchin M, De Ponti R, De Ponti F, Ageno W. Emerging therapeutic uses of direct-acting oral anticoagulants: An evidence-based perspective. Pharmacol Res 2017; 120:206-218. [PMID: 28366835 DOI: 10.1016/j.phrs.2017.03.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 03/22/2017] [Accepted: 03/29/2017] [Indexed: 12/24/2022]
Abstract
Direct-acting oral anticoagulants (DOACs) were claimed to cause a potential paradigm shift in the therapeutic scenario of patients requiring short- and long-term anticoagulation, by virtue of their pharmacological properties, perceived as innovative. The evidence gathered so far (from pre-approval pivotal trials to real-world post-marketing observational data) consistently confirmed that DOACs are overall comparable to vitamin-K antagonists (VKAs) in terms of safety, efficacy and effectiveness and unequivocally documented a consistent and clinically relevant reduced risk of intracranial bleeding in the settings of non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE). Interestingly, two parallel paths can be identified in the current research scenario: A) in the aforementioned consolidated therapeutic indications, an innovative approach is directed towards tailored treatment strategies, to identify patients most likely to benefit from one of the different anticoagulant drugs, in particular subpopulations at increased risk of adverse events (e.g., bleeding); B) in unconventional settings, DOACs are gaining interest for potential use in emerging diseases characterized by arterial and venous thromboembolic risk. In these scenarios, the risk-benefit profile of DOACs, as compared to VKAs or heparins, is less defined. The aim of this review is to critically assess the body of evidence underlying emerging therapeutic uses of DOACs (e.g., heparin-induced thrombocytopenia, anti-phospholipid antibody syndrome), including evolving issues in special populations (e.g., patients with VTE and cancer or cirrhosis). This will be achieved by analyzing the strength (i.e., systematic reviews, randomized clinical trials, observational studies, case report/series) and consistency (i.e., concordance) of both published and unpublished evidence registered in major public repositories.
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Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Matteo Bianchin
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberto De Ponti
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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36
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Liew A, Douketis J. Portal vein thrombosis in patients with cirrhosis: underdiagnosis and undertreatment? Intern Emerg Med 2016; 11:1037-1040. [PMID: 27216797 DOI: 10.1007/s11739-016-1463-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 05/06/2016] [Indexed: 01/17/2023]
Affiliation(s)
- Aaron Liew
- Portiuncula University Hospital & Galway University Hospital, Saolta University Health Care Group, Galway, Ireland
- National University of Ireland Galway (NUIG), Galway, Ireland
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - James Douketis
- St. Joseph's Healthcare, Department of Medicine, McMaster University, F-544, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada.
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37
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Yang H, Kim SR, Song MJ. Recurrent acute portal vein thrombosis in liver cirrhosis treated by rivaroxaban. Clin Mol Hepatol 2016; 22:499-502. [PMID: 27880998 PMCID: PMC5266341 DOI: 10.3350/cmh.2016.0016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 06/28/2016] [Accepted: 06/29/2016] [Indexed: 12/13/2022] Open
Abstract
Cirrhosis can occur with the development of portal vein thrombosis (PVT). PVT may aggravate portal hypertension, and it can lead to hepatic decompensation. The international guideline recommends for anticoagulation treatment to be maintained for at least 3 months in all patients with acute PVT. Low-molecular-weight-heparin and changing to warfarin is the usual anticoagulation treatment. However, warfarin therapy is problematic due to a narrow therapeutic window and the requirement for frequent dose adjustment, which has prompted the development of novel oral anticoagulants for overcoming these problems. We report a 63-year-old female who experienced complete resolution of recurrent acute PVT in liver cirrhosis after treatment with rivaroxaban.
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Affiliation(s)
- Hyeyoung Yang
- Division of Hepatology, Department of Internal Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Seo Ree Kim
- Division of Hepatology, Department of Internal Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Myeong Jun Song
- Division of Hepatology, Department of Internal Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
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38
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Intagliata NM, Ferreira CN, Caldwell SH. Anticoagulación en la trombosis de la vena porta en la cirrosis. Clin Liver Dis (Hoboken) 2016; 8:S10-S15. [PMID: 31041089 PMCID: PMC6490226 DOI: 10.1002/cld.599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 03/14/2016] [Indexed: 02/04/2023] Open
Affiliation(s)
- Nicolas M. Intagliata
- Division of Gastroenterology and Hepatology, Center for Coagulation in Liver DiseaseUniversity of Virginia Medical CenterCharlottesvilleVA, EE. UU., y
| | - Carlos N. Ferreira
- Servico de Gastrenterologia e Hepatologia, Hospital de Santa MariaCentro Hospitalar Lisboa NorteLisboaPortugal
| | - Stephen H. Caldwell
- Division of Gastroenterology and Hepatology, Center for Coagulation in Liver DiseaseUniversity of Virginia Medical CenterCharlottesvilleVA, EE. UU., y
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39
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Xue S, Zhang Q, Liu J, Wang PS, Chen G. Diagnosis and treatment of portal vein thrombosis after splenectomy and gastroesophageal devascularization. Shijie Huaren Xiaohua Zazhi 2016; 24:4063-4069. [DOI: 10.11569/wcjd.v24.i29.4063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Splenectomy and gastroesophageal devascularization is the most common clinical treatment for upper gastrointestinal bleeding in patients with portal hypertension. Its advantages include exact treatment and little impact on liver function. However, due to the postoperative high blood coagulation state and hemodynamic changes, it greatly increases the incidence of portal vein thrombosis (PVT), which causes serious complications. Ultrasound, CT and MRI are main methods for the diagnosis of PVT. After diagnosis, using anticoagulation, intervention and surgery can achieve effective control and treatment. PVT mostly occurs perioperatively and therapeutic effects are therefore limited, so perioperative PVT prevention is particularly important. It is recommended that anticoagulation drugs be given preoperatively to prevent PVT formation, injury to the vascular endothelium of the portal vein system be avoided intraoperatively to reduce the formation of spleen vein stump and stabilize postoperative portal vein blood flow dynamics, and ultrasound be performed postoperatively to achieve early diagnosis and treatment.
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40
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Intagliata NM, Ferreira CN, Caldwell SH. Anticoagulation for portal vein thrombosis in cirrhosis. Clin Liver Dis (Hoboken) 2016; 7:126-131. [PMID: 31041046 PMCID: PMC6490275 DOI: 10.1002/cld.552] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 02/24/2016] [Accepted: 03/14/2016] [Indexed: 02/04/2023] Open
Affiliation(s)
- Nicolas M. Intagliata
- Division of Gastroenterology and Hepatology, Center for Coagulation in Liver DiseaseUniversity of Virginia Medical CenterCharlottesvilleVA
| | - Carlos N. Ferreira
- Servico de Gastrenterologia e Hepatologia, Hospital de Santa MariaCentro Hospitalar Lisboa NorteLisbonPortugal
| | - Stephen H. Caldwell
- Division of Gastroenterology and Hepatology, Center for Coagulation in Liver DiseaseUniversity of Virginia Medical CenterCharlottesvilleVA
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41
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Intagliata NM, Henry ZH, Maitland H, Shah NL, Argo CK, Northup PG, Caldwell SH. Direct Oral Anticoagulants in Cirrhosis Patients Pose Similar Risks of Bleeding When Compared to Traditional Anticoagulation. Dig Dis Sci 2016; 61:1721-7. [PMID: 26725062 DOI: 10.1007/s10620-015-4012-2] [Citation(s) in RCA: 170] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Direct oral anticoagulants (DOAC) are important new anticoagulant therapies that are not well studied in patients with chronic liver disease. The aim of this study was to compare rates of bleeding in cirrhosis patients treated with DOAC (factor Xa inhibitors: rivaroxaban and apixaban) to those in cirrhosis patients treated with traditional anticoagulation (warfarin and low molecular weight heparin). METHODS We identified a total of 39 patients with cirrhosis who received anticoagulation therapy over a 3-year period (20 DOAC and 19 traditional anticoagulation) from a research database. Medical records were reviewed to obtain clinical data to compare between the groups. RESULTS Clinical characteristics between the two groups were similar. There were three documented bleeding events in the traditional anticoagulation group and four bleeding events in the DOAC group (p = 0.9). There were two major bleeding events in the traditional anticoagulation group and one major bleeding event in the DOAC group. There were no documented reports of drug-induced liver injury during this study period. Among all patients, no significant predictors of bleeding were identified using univariate regression and Cox proportional hazard modeling. CONCLUSIONS This is the first clinical study evaluating the use of DOAC in patients with cirrhosis. DOAC display similar safety characteristics when compared to traditional anticoagulation in patients with cirrhosis and are potentially attractive agents for anticoagulation therapy. Larger studies are now needed to better understand the safety and efficacy of these agents in cirrhosis.
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Affiliation(s)
- N M Intagliata
- Coagulation in Liver Disease Study Group, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, 22908, USA.
| | - Z H Henry
- Coagulation in Liver Disease Study Group, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, 22908, USA
| | - H Maitland
- Division of Hematology and Oncology, University of Virginia Medical Center, PO Box 800716, Charlottesville, VA, 22908, USA
| | - N L Shah
- Coagulation in Liver Disease Study Group, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, 22908, USA
| | - C K Argo
- Coagulation in Liver Disease Study Group, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, 22908, USA
| | - P G Northup
- Coagulation in Liver Disease Study Group, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, 22908, USA
| | - S H Caldwell
- Coagulation in Liver Disease Study Group, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, 22908, USA
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Abstract
OPINION STATEMENT The risk of thrombosis in patients with chronic liver disease is increasingly recognized. As patients with cirrhosis develop indications for anticoagulation therapy (e.g., venous thromboembolism, portal vein thrombosis, or atrial fibrillation), providers are left to make difficult decisions when selecting therapeutics with little evidence to rely on. Current practice supports the use of low molecular weight heparin or vitamin K antagonists in select patients with cirrhosis requiring anticoagulation. While traditional anticoagulants may be safe and effective in select patients with compensated cirrhosis, the use of direct oral anticoagulants (DOAC) is more controversial. DOAC are desirable as they do not require routine monitoring and can be taken orally. Unfortunately, patients with chronic liver disease were excluded from clinical trials that demonstrated efficacy and safety when compared to traditional anticoagulation. Data are now emerging that support the use of DOAC in well-compensated cirrhosis patients. However, further study is needed with all (traditional and DOAC) anticoagulation medications in patients with cirrhosis to better ensure safety and further understand pharmacologic properties in this challenging population.
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Affiliation(s)
- Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, Center for Coagulation in Liver Disease, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, USA.
| | - Hillary Maitland
- Division of Hematology, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, Center for Coagulation in Liver Disease, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, USA
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Finazzi G, Ageno W. Direct oral anticoagulants in rare venous thrombosis. Intern Emerg Med 2016; 11:167-70. [PMID: 26875179 DOI: 10.1007/s11739-016-1398-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 01/19/2016] [Indexed: 12/12/2022]
Abstract
The direct inhibitors of thrombin (dabigatran) or factor Xa (rivaroxaban, apixaban) are currently used in patients with venous thrombosis of the lower or upper limbs or with pulmonary embolism. However, the use of these direct oral anticoagulants (DOACs) in subjects with abdominal or cerebral venous thrombosis is more contentious due to the paucity of available data. In a few case reports and small series of patients hitherto published, the DOACs showed good efficacy and safety, supporting an extension of their use to these rare conditions. Thus, prospective cohort studies and randomized controlled trials have been set up. In this article, we review the published clinical experience with DOACs in rare venous thrombosis, and provide updated information on ongoing clinical trials.
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Affiliation(s)
- Guido Finazzi
- USS Malattie Mieloproliferative Croniche, USC Ematologia, Ospedale Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy.
| | - Walter Ageno
- Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi dell'Insubria, Varese, Italy
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44
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Chen H, Turon F, Hernández-Gea V, Fuster J, Garcia-Criado A, Barrufet M, Darnell A, Fondevila C, Garcia-Valdecasas JC, Garcia-Pagán JC. Nontumoral portal vein thrombosis in patients awaiting liver transplantation. Liver Transpl 2016; 22:352-65. [PMID: 26684272 DOI: 10.1002/lt.24387] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/06/2015] [Accepted: 11/25/2015] [Indexed: 02/06/2023]
Abstract
Portal vein thrombosis (PVT) occurs in approximately 2%-26% of the patients awaiting liver transplantation (LT) and is no longer an absolute contraindication for LT. Nearly half of PVT cases are accidentally found during the LT procedure. The most important risk factor for PVT development in cirrhosis may be the severity of liver disease and reduced portal blood flow. Whether other inherited or acquired coagulation disorders also play a role is not yet clear. The development of PVT may have no effect on the liver disease progression, especially when it is nonocclusive. PVT may not increase the risk of wait-list mortality, but it is a risk factor for poor early post-LT mortality. Anticoagulation and transjugular intrahepatic portosystemic shunt (TIPS) are 2 major treatment strategies for patients with PVT on the waiting list. The complete recanalization rate after anticoagulation is approximately 40%. The role of TIPS to maintain PV patency for LT as the primary indication has been reported, but the safety and efficacy should be further evaluated. PVT extension and degree may determine the surgical technique to be used during LT. If a "conventional" end-to-end portal anastomotic technique is used, there is not a major impact on post-LT survival. Post-LT PVT can significantly reduce both graft and patient survival after LT and can preclude future options for re-LT.
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Affiliation(s)
- Hui Chen
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Barcelona, Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Josep Fuster
- HBP Surgery and Liver Transplantation Unit, University of Barcelona, Barcelona, Spain
| | - Angeles Garcia-Criado
- Department of Radiology, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Marta Barrufet
- Department of Radiology, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Anna Darnell
- Department of Radiology, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Constantino Fondevila
- HBP Surgery and Liver Transplantation Unit, University of Barcelona, Barcelona, Spain
| | | | - Juan Carlos Garcia-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
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Ageno W, Beyer-Westendorf J, Garcia DA, Lazo-Langner A, McBane RD, Paciaroni M. Guidance for the management of venous thrombosis in unusual sites. J Thromb Thrombolysis 2016; 41:129-43. [PMID: 26780742 PMCID: PMC4715841 DOI: 10.1007/s11239-015-1308-1] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Venous thromboembolism (VTE) is a serious and often fatal medical condition with an increasing incidence. The treatment of VTE is undergoing tremendous changes with the introduction of the new direct oral anticoagulants and clinicians need to understand new treatment paradigms. This manuscript, initiated by the Anticoagulation Forum, provides clinical guidance based on existing guidelines and consensus expert opinion where guidelines are lacking. In this chapter, we address the management of patients presenting with venous thrombosis in unusual sites, such as cerebral vein thrombosis, splanchnic vein thrombosis, and retinal vein occlusion. These events are less common than venous thrombosis of the lower limbs or pulmonary embolism, but are often more challenging, both for the severity of clinical presentations and outcomes and for the substantial lack of adequate evidence from clinical trials. Based on the available data, we suggest anticoagulant treatment for all patients with cerebral vein thrombosis and splanchnic vein thrombosis. However, in both groups a non-negligible proportion of patients may present with concomitant bleeding at the time of diagnosis. This should not contraindicate immediate anticoagulation in patients with cerebral vein thrombosis, whereas for patients with splanchnic vein thrombosis anticoagulant treatment should be considered only after the bleeding source has been successfully treated and after a careful assessment of the risk of recurrence. Finally, there is no sufficient evidence to support the routine use of antithrombotic drugs in patients with retinal vein occlusion. Future studies need to assess the safety and efficacy of the direct oral anticoagulants in these settings.
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Affiliation(s)
- Walter Ageno
- Department of Clinical and Experimental Medicine, University of Insubria, Via Guicciardini 9, 21100, Varese, Italy.
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46
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Abstract
Portal vein thrombosis is an unusual thrombotic condition not frequently seen in the general population; however, it has a higher prevalence in special circumstances such as in liver cirrhosis and hepatic or pancreatic malignancy. It also can be associated with significant morbidity and mortality. In this review, we discuss the current data available to guide therapy in the setting of different associated co-morbidities, hypercoagulable states, and associated thrombosis of the remaining splanchnic circulation. We discuss indications for anticoagulation, including the choice of anticoagulants, as well as the role of conservative 'wait and watch' and invasive therapies, such as thrombolysis, thrombectomy, and transjugular intrahepatic portosystemic shunt.
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Affiliation(s)
- Aditya M Sharma
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville, VA, USA
| | - Daisy Zhu
- Medical Education, University of Virginia, Charlottesville, VA, USA
| | - Zachary Henry
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
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47
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Sabol TP, Molina M, Wu GY. Thrombotic Venous Diseases of the Liver. J Clin Transl Hepatol 2015; 3:189-94. [PMID: 26623265 PMCID: PMC4663200 DOI: 10.14218/jcth.2015.00014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/01/2015] [Accepted: 06/03/2015] [Indexed: 02/06/2023] Open
Abstract
Thrombotic venous diseases of the liver do not occur frequently, but when they do, they can present as difficult diagnostic and therapeutic challenges. The aim of this article is to review the epidemiology, pathogenesis, diagnosis, and therapeutic options of these serious vascular problems.
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Affiliation(s)
- Timothy P. Sabol
- Department of Graduate Medical Education, Eastern Connecticut Health Network, Manchester Memorial Hospital, Manchester, CT, USA
| | - Marco Molina
- Department of Radiology, University of Connecticut Health Center, Farmington, CT, USA
| | - George Y. Wu
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
- Correspondence to: George Y. Wu, Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, AM-045, Farmington, CT 06001, USA. Tel: +1-800-535-6232; +1-860-679-7692, Fax: +1-860-679-3159, E-mail:
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48
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Ikura Y, Osuga T. Changing common sense: Anti-platelet/coagulation therapy against cirrhosis. World J Hepatol 2015; 7:1730-1734. [PMID: 26167245 PMCID: PMC4491901 DOI: 10.4254/wjh.v7.i13.1730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 03/29/2015] [Accepted: 04/30/2015] [Indexed: 02/06/2023] Open
Abstract
Until recently, anti-platelet/coagulation therapy had not been recommended for patients with cirrhosis. Although venous thrombosis is one of the representative complications of cirrhosis and ischemic disorders associated with atherosclerosis are not infrequent in cirrhotic patients, many clinicians have tended to hesitate to introduce anti-platelet/coagulation therapy to their patients. Undoubtedly, this is due to the increased risk of hemorrhagic diathesis in cirrhotic patients. However, accumulating evidence has revealed the benefits of anti-platelet/coagulation therapy for cirrhotic patients. In addition to the safety of the therapy carried out against cardiovascular diseases in cirrhotic patients, some clinical data have indicated its preventive effect on venous thrombosis. Moreover, the efficacy of anti-platelet/coagulation therapy against cirrhosis itself has been demonstrated both clinically and experimentally. The conceptual basis for application of anti-platelet/coagulation therapy against cirrhosis was constructed through two pathologic studies on intrahepatic thrombosis in cirrhotic livers. It may be better to use thrombopoietin-receptor agonists, which have been tested as a treatment for cirrhosis-related thrombocytopenia, in combination with anti-platelet drugs to reduce the risk of venous thrombosis. During the last decade, the World Journal of Gastroenterology, a sister journal of World Journal of Hepatology, has been one of the main platforms of active discussion of this theme.
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49
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Harding DJ, Perera MTPR, Chen F, Olliff S, Tripathi D. Portal vein thrombosis in cirrhosis: Controversies and latest developments. World J Gastroenterol 2015; 21:6769-84. [PMID: 26078553 PMCID: PMC4462717 DOI: 10.3748/wjg.v21.i22.6769] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 03/12/2015] [Accepted: 05/07/2015] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) is encountered in liver cirrhosis, particularly in advanced disease. It has been a feared complication of cirrhosis, attributed to significant worsening of liver disease, poorer clinical outcomes and potential inoperability at liver transplantation; also catastrophic events such as acute intestinal ischaemia. Optimal management of PVT has not yet been addressed in any consensus publication. We review current literature on PVT in cirrhosis; its prevalence, pathophysiology, diagnosis, impact on the natural history of cirrhosis and liver transplantation, and management. Studies were identified by a search strategy using MEDLINE and Google Scholar. The incidence of PVT increases with increasing severity of liver disease: less than 1% in well-compensated cirrhosis, 7.4%-16% in advanced cirrhosis. Prevalence in patients undergoing liver transplantation is 5%-16%. PVT frequently regresses instead of uniform thrombus progression. PVT is not associated with increased risk of mortality. Optimal management has not been addressed in any consensus publication. We propose areas for future research to address unresolved clinical questions.
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50
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Simonetto DA, Wysokinski WE, Kamath PS. Use of nontraditional anticoagulants in portal vein thrombosis: a note of caution. Hepatology 2015; 61:2119. [PMID: 25266497 DOI: 10.1002/hep.27541] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
| | | | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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