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Zhu J, Xia Y, Liu X, Zhang C. Preventing variceal rebleeding in cirrhotic patients with portal vein thrombosis: A systematic review and meta-analysis. J Gastroenterol Hepatol 2024; 39:642-648. [PMID: 38233086 DOI: 10.1111/jgh.16489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND AIM Preventing rebleeding is crucial, but the best prevention technique for patients with cirrhosis and portal vein thrombosis (PVT) remains debatable. Therefore, this systematic review and meta-analysis compared a transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic therapy (ET) plus nonselective beta-blockers (NSBBs) for preventing variceal rebleeding in this patient population. METHODS The PubMed, Embase, Cochrane Library, and Web of Science databases were searched from their inception until May 18, 2023. The studies were screened using predetermined criteria, relevant data were extracted, and pooled analyses were performed using the Reviewer Manager 5.4.1 software. RESULTS We retrieved 1032 studies, of which 5 studies comprising a total of 272 patients were included. The postoperative variceal rebleeding rate was significantly lower in the TIPS group than in the ET + NSBBs group (odds ratio [OR] = 0.19, 95% confidence interval [CI] = 0.11-0.35, P < 0.05, I2 = 0%), but the portal vein recanalization rate was higher (OR = 7.92, 95% CI = 3.04-20.67, P < 0.05, I2 = 0%). The rates of hepatic encephalopathy (HE) and mortality did not differ between the groups. CONCLUSIONS Our results suggest that TIPS prevents variceal rebleeding without increasing the hepatic encephalopathy risk more effectively than ET plus NSBBs, but this benefit did not translate into improved survival. Thus, it may be preferable to ET plus NSBBs for preventing variceal rebleeding in patients with cirrhosis and PVT. However, more large-scale and multicenter randomized controlled trials involving other patient populations are required to verify the clinical efficacy of both these treatments and ensure generalizability.
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Affiliation(s)
- Junyuan Zhu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yifu Xia
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Xiao Liu
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, China
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2
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Berengy MS, Abd El-Hamid Hassan EM, Ibrahim AH, Mohamed EF. Safety and efficacy of transjugular intrahepatic portosystemic shunts vs endoscopic band ligation plus propranolol in patients with cirrhosis with portal vein thrombosis: a systematic review and meta-analysis. J Gastrointest Surg 2024; 28:316-326. [PMID: 38445926 DOI: 10.1016/j.gassur.2023.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/20/2023] [Accepted: 12/30/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND This systematic review and meta-analysis aimed to assess the efficacy and safety of transjugular intrahepatic portosystemic shunts (TIPS) against the combined treatment of endoscopic band ligation (EBL) and propranolol in managing patients with cirrhosis diagnosed with portal vein thrombosis (PVT). METHODS A literature search from inception to September 2023 was performed using MEDLINE, the Cochrane Library, Web of Science, and Scopus. Independent screening, data extraction, and quality assessment were performed. The main measured outcomes were the incidence and recurrence of variceal bleeding (VB), hepatic encephalopathy, and overall survival. RESULTS A total of 5 studies were included. For variceal eradication, there was initially no significant difference between the groups; however, after sensitivity analysis, a significant effect emerged (risk ratio [RR], 1.55; P < .0001). TIPS was associated with a significant decrease in the incidence of VB (RR, 0.34; P < .0001) and a higher probability of remaining free of VB in the first 2 years after the procedure (first year: RR, 1.41; P < .0001; second year: RR, 1.58; P < .0001). TIPS significantly reduced the incidence of death due to acute GI bleeding compared with EBL + propranolol (RR, 0.37; P = .05). CONCLUSION TIPS offers a comprehensive therapeutic advantage over the combined EBL and propranolol regimen, especially for patients with cirrhosis with PVT. Its efficacy in variceal eradication, reducing rebleeding, and mitigating death risks due to acute GI bleeding is evident.
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Affiliation(s)
- Mahmoud Saad Berengy
- Department of Internal Medicine, Damietta Faculty of Medicine, Al-Azhar University, Damietta, Egypt.
| | | | - Amal H Ibrahim
- Department of Internal Medicine, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | - Eman F Mohamed
- Department of Internal Medicine, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
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Senzolo M, Shalaby S, Grasso M, Vitale A, Pizzirani E, Barbiero G, Zanetto A, Feltracco P, Simioni P, Burra P, Cillo U. Role of nonneoplastic PVT in the natural history of patients with cirrhosis and first diagnosis of HCC. Hepatology 2024; 79:355-367. [PMID: 37505218 DOI: 10.1097/hep.0000000000000538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 07/01/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND AND AIMS HCC can increase the risk of nonneoplastic PVT in cirrhosis. However, the natural history of PVT and its prognostic role in HCC patients are unknown. APPROACH AND RESULTS Consecutive HCC patients with cirrhosis undergoing laparoscopic ablation were retrospectively evaluated and followed up to 36 months. HCC and PVT characteristics and evolution were reviewed. PVT was categorized according to lumen occupancy (≤50%, >50% <100%, and = 100%) and extension to other veins. The evolution of thrombosis was considered at 1 year from diagnosis. Variables associated with the presence of PVT and evolution patterns were analyzed, as well as their impact on survival. In all, 750 patients were included, 88 of whom had PVT. On multivariate analysis, the occurrence of PVT at HCC diagnosis was associated with pretreatment total tumor volume ( p < 0.001) and clinically significant portal hypertension ( p = 0.005). During the follow-up, 46 de novo PVT occurred, 27/46 (58.7%) in the presence of a viable tumor. Among 115 PVT diagnosed in the presence of HCC, 83 had available radiological follow-up, and 22 were anticoagulated. The "complete/progressive" evolution pattern was associated with nonresponse to HCC treatment in non-anticoagulated patients. The presence of PVT was independently associated with lower overall survival, particularly when progressive or occlusive ( p < 0.001). A higher competing risk of death emerged for "complete and progressive" PVT, both for HCC-related ( p < 0.001) and non-HCC-related ( p = 0.002) death. CONCLUSIONS HCC represents an independent risk factor for the occurrence and progression of PVT in cirrhosis. Since progressive and occlusive PVT seems to be an independent factor associated with mortality, screening and prompt treatment of this complication should be considered.
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Affiliation(s)
- Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Sarah Shalaby
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Marco Grasso
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Alessandro Vitale
- General Surgery 2-Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy
| | - Enrico Pizzirani
- Institute of Radiology, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Giulio Barbiero
- Institute of Radiology, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Paolo Feltracco
- Anesthesiology and Intensive Care in Complex Surgery and Transplantology, Padova University Hospital, Padova, Italy
| | - Paolo Simioni
- General Internal Medicine, Hemorrhagic and Thrombotic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Umberto Cillo
- General Surgery 2-Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy
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Lv Y, Bai W, Zhu X, Xue H, Zhao J, Zhuge Y, Sun J, Zhang C, Ding P, Jiang Z, Zhu X, Ren W, LiZhang YK, Zhang W, Li K, Wang Z, Luo B, Li X, Yuan J, Yang Z, Guo W, Xia D, Xie H, Yang C, Pan Y, Yin Z, Fan D, Han G. Association of nonmalignant portal vein thrombosis and clinical outcomes in patients with cirrhosis and acute variceal bleeding: a multicenter observational study. Hepatol Int 2023; 17:1192-1204. [PMID: 37258989 DOI: 10.1007/s12072-023-10493-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/20/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND AND AIM Baveno VII workshop recommends management of acute variceal bleeding (AVB) in cirrhotic patients with nonmalignant portal vein thrombosis (PVT) should be performed according to the guidelines for patients without PVT. Nevertheless, whether PVT affects the outcome of patients with cirrhosis and AVB remains unclear. The aim of this study was to assess the clinical impact of PVT on the outcomes in the pre-emptive TIPSS eligible patients with cirrhosis and AVB. METHODS From December 2010 to June 2016, 1219 consecutive cirrhotic patients admitted due to AVB with (n = 151; 12.4%) or without PVT (n = 1068; 87.6%), who received drug plus endoscopic treatment (a combination of vasoactive drugs, antibiotics, and endoscopic ligation for AVB, followed by beta-blockers plus variceal ligation for prevention of rebleeding) were retrospectively included. Fine and Gray competing risk regression models were taken to evaluate the impact of PVT on clinical outcomes after adjusting for potential confounders. RESULTS During follow-up, 211 patients (17.3%) died, 490 (40.2%) experienced further bleeding, and 78 (6.4%) experienced new or worsening ascites within 1 year. Compared with those without PVT, patients with PVT had a similar risk of mortality (PVT vs no-PVT: 19.9% vs 16.7% at 1 year; adjusted HR 0.88, 95%CI 0.51-1.52, p = 0.653), further bleeding (47.0% vs 39.2% at 1 year, adjusted HR 1.19, 95% CI 0.92-1.53, p = 183), and new or worsening ascites (7.9% vs 9.6%, adjusted HR 0.70, 95% CI 0.39-1.28, p = 0.253) after adjusting for confounders in multivariable models. These findings were consistent across different relevant subgroups and confirmed by propensity score matching analysis. CONCLUSIONS Our study showed no evidence that the PVT was associated with an improved or worsened outcome among cirrhotic patients with AVB who received standard treatment.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Military Medical Innovation Center, Fourth Military Medical University, Xi'an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Xuan Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hui Xue
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jianbo Zhao
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Junhui Sun
- Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Hepatobiliary and Pancreatic Intervention Center, Zhejiang University, Hangzhou, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Pengxu Ding
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zaibo Jiang
- Department of Interventional Radiology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiaoli Zhu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Weixin Ren
- Department of Interventional Radiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yingchun Kewei LiZhang
- Department of Interventional Radiology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
- Department of Vascular Surgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Wenguang Zhang
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Zhiping Yang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Dongdong Xia
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Huahong Xie
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Changbing Yang
- Military Medical Innovation Center, Fourth Military Medical University, Xi'an, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
- Department of Liver Diseases and Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, No,777 Xitai Road, High-Tech Zone, Xi'an, 710100, China.
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Tie J, Gou X, He C, Li K, Yuan X, Jia W, Niu J, Han N, Xu J, Zhu Y, Wang W. Transjugular intrahepatic collateral-systemic shunt is effective for cavernous transformation of the portal vein with variceal bleeding. Hepatol Int 2023; 17:979-988. [PMID: 37097537 PMCID: PMC10386942 DOI: 10.1007/s12072-023-10522-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/13/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND The transjugular intrahepatic portal collateral-systemic shunt (transcollateral TIPS) is used to treat portal hypertension-related complications in patients with cavernous transformation of the portal vein (CTPV) and whose main portal vein cannot be recanalized. It is still not clear whether transcollateral TIPS can be as effective as portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS). This study aimed to evaluate the efficacy and safety of transcollateral TIPS in the treatment of refractory variceal bleeding with CTPV. METHODS Patients with refractory variceal bleeding caused by CTPV were selected from the database of consecutive patients treated with TIPS in Xijing Hospital from January 2015 to March 2022. They were divided into the transcollateral TIPS group and the PVR-TIPS group. The rebleeding rate, overall survival, shunt dysfunction, overt hepatic encephalopathy (OHE) and operation-related complications were analyzed. RESULTS A total of 192 patients were enrolled, including 21 patients with transcollateral TIPS and 171 patients with PVR-TIPS. Compared with the patients with PVR-TIPS, the patients with transcollateral TIPS had more noncirrhosis (52.4 vs. 19.9%, p = 0.002), underwent fewer splenectomies (14.3 vs. 40.9%, p = 0.018), and had more extensive thromboses (38.1 vs. 15.2%, p = 0.026). There were no differences in rebleeding, survival, shunt dysfunction, or operation-related complication rates between the transcollateral TIPS and PVR-TIPS groups. However, the OHE rate was significantly lower in the transcollateral TIPS group (9.5 vs. 35.1%, p = 0.018). CONCLUSION Transcollateral TIPS is an effective treatment for CTPV with refractory variceal bleeding.
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Affiliation(s)
- Jun Tie
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China.
| | - Xiaoyuan Gou
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Chuangye He
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Kai Li
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Xulong Yuan
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Wenyuan Jia
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Jing Niu
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Na Han
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Jiao Xu
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Ying Zhu
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Wenlan Wang
- Department of Aerospace Hygiene, School of Aerospace Medicine, Air Force Medical University, Xi'an, 710032, Shaanxi, China.
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Guo DF, Fan LW, Le Q, Huang CB. Transjugular intrahepatic portosystemic shunt for the prevention of rebleeding in patients with cirrhosis and portal vein thrombosis: Systematic review and meta-analysis. Front Pharmacol 2022; 13:968988. [PMID: 36052145 PMCID: PMC9424732 DOI: 10.3389/fphar.2022.968988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Transjugular intrahepatic portosystemic shunt (TIPS) has been performed on patients with cirrhosis and portal vein thrombosis (PVT) to prevent rebleeding; however, the associated evidence is scarce. Hence, the study aimed to evaluate the feasibility and efficacy of TIPS in patients with cirrhosis and PVT and promote personalized treatment in such patients. Methods: Literature was systematically obtained from PubMed, EMBASE, Cochrane Library, and Web of Science. Data from the included studies were extracted, and meta-analyses by the random effects model were used to pool data across studies. Heterogeneity was assessed using Cochran’s Q and I2 statistics. The source of heterogeneity was explored using subgroup analyses and meta-regressions. Results: A total of 11 studies comprising 703 patients with cirrhosis and portal vein thrombosis (PVT: complete, 32.2%; chronic, 90.2%; superior mesenteric vein or splenic vein involvement, 55.2%; cavernous transformation, 26.8%) were included. TIPS showed feasibility in 95% of the cases (95% confidence interval [CI]: 89%–99%) with heterogeneity (I2 = 84%, p < 0.01) due to cavernous transformation. The pooled rebleeding rate was 13% (95% CI: 7%–20%) with heterogeneity (I2 = 75%, p < 0.01) explained by chronic PVT and anticoagulation (AC) therapy. Hepatic encephalopathy occurred in 32% of patients. The survival rate, portal vein recanalization rate, and shunt patency rate were 80%, 82%, and 77%, respectively. Conclusion: TIPS is feasible and effectively prevents rebleeding in patients with cirrhosis and PVT, regardless of cavernous transformation of the portal vein. Due to a potentially high risk of rebleeding and no apparent benefits of AC, post-TIPS AC must be employed cautiously. Systematic Review Registration: [https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=258765], identifier [CRD42021258765].
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Affiliation(s)
- Ding-Fan Guo
- Department of Gastroenterology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Lin-Wei Fan
- The First Clinical Medical School of Nanchang University, Nanchang, China
- Key Laboratory of Jiangxi Province for Transfusion Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qi Le
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Cai-Bin Huang
- Department of Gastroenterology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- *Correspondence: Cai-Bin Huang,
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7
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Senzolo M, Piano S, Shalaby S, Tonon M, Tonello S, Zanetto A, Sacerdoti D, Simioni P, Bombonato G, Burra P, Angeli P. Comparison of Fondaparinux and Low-Molecular-Weight Heparin in the Treatment of Portal Vein Thrombosis in Cirrhosis. Am J Med 2021; 134:1278-1285.e2. [PMID: 34197784 DOI: 10.1016/j.amjmed.2021.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 03/02/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Portal vein thrombosis is the most common thrombotic complication in cirrhosis. About 60% of anticoagulated patients can achieve recanalization. Despite fondaparinux (FPX) theoretical advantages, data are lacking about safety and efficacy for treatment of portal vein thrombosis in cirrhosis. METHODS Cirrhotic patients with portal vein thrombosis treated with FPX or low-molecular-weight heparin (LMWH) were retrospectively included. The extension of thrombosis at baseline and its evolution during anticoagulant treatment were evaluated. Patients were treated with LMWH or FPX at therapeutic dosage and reduction was considered in selected cases. RESULTS There were 124 patients included. Main portal vein branch, splenic, and superior mesenteric veins were involved in 84%, 13%, and 36% of cases, respectively. Forty-one patients (33%) were treated with FPX and 83 (67%) with LMWH. The probability of resolution of thrombosis at 36 months was significantly higher in patients treated with FPX than in those treated with LMWH (77% vs 51%; P = .001), particularly when prescribed at reduced dose. With multivariate analysis, the treatment with FPX (hazard ratio 2.38; P = .002) and use of a full dose (hazard ratio 1.78; P = .035) were independent predictors of portal vein full recanalization. Bleeding rate was higher in patients treated with FPX than in those treated with LMWH (27% vs 13%; P = .06). CONCLUSIONS FPX appears to be more effective than LMWH in the treatment of portal vein thrombosis when used at reduced dose, also in complete thrombosis. FPX should be considered among possible treatments for portal vein thrombosis in cirrhosis.
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Affiliation(s)
- Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology.
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine-DIMED
| | - Sarah Shalaby
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology
| | - Marta Tonon
- Unit of Internal Medicine and Hepatology, Department of Medicine-DIMED
| | - Silvia Tonello
- Unit of Internal Medicine and Hepatology, Department of Medicine-DIMED
| | - Alberto Zanetto
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology
| | - David Sacerdoti
- Unit of Internal Medicine and Hepatology, Department of Medicine-DIMED
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | | | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine-DIMED
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8
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Han JB, Shu QH, Zhang YF, Yi YX. Predictive Value of Inflammation Biomarkers in Patients with Portal Vein Thrombosis. J Clin Transl Hepatol 2021; 9:384-391. [PMID: 34221924 PMCID: PMC8237143 DOI: 10.14218/jcth.2020.00159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/09/2021] [Accepted: 02/26/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND AIMS To investigate the usefulness of inflammation biomarkers to serve as a predictors of portal vein thrombosis (PVT) postoperatively (post) in patients with portal hypertension after splenectomy and periesophagogastric devascularization. METHODS A total of 177 liver cirrhosis patients were recruited from January 2013 to December 2017. They were divided into a PVT group (n=71) and a non-PVT group (n=106), according to ultrasound examination findings at 7-day post. Inflammation biomarkers involving platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), red blood cell distribution width-to-platelet ratio(RPR), mean platelet volume-to-platelet ratio (MPR) preoperatively (pre) and at 1, 3, 7-days post were recorded. RESULTS The univariate logistic regression analysis indicated that PLR (pre) (odds ratio (OR)=3.963, 95% confidence interval (CI)=2.070-7.587, p<0.000), MLR (pre) (OR=2.760, 95% CI=1.386-5.497, p=0.004), PLR (post-day 7) (OR=3.345, 95% CI=1.767-6.332, p=0.000) were significantly associated with the presence of PVT. The multivariate logistic regression analysis results indicated that PLR (pre) (OR=3.037, 95% CI=1.463-6.305, p=0.003), MLR (pre) (OR=2.188, 95% CI=1.003-4.772, p=0.049), PLR(post-day 7) (OR=2.166, 95% CI=1.053-4.454, p=0.036) were independent factors for predicting PVT. CONCLUSIONS The PLR (pre), MLR (pre), and PLR (post-day 7) are predictors of portal vein thrombosis post in patients with portal hypertension after splenectomy and periesophagogastric devascularization.
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Affiliation(s)
| | | | - Yu-Feng Zhang
- Correspondence to: Yu-Feng Zhang and Yong-Xiang Yi, Department of Hepatopancreatobiliary Surgery, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, No. 1 Zhongfu Road, Nanjing, Jiangsu 210003, China. Tel/Fax: +86-25-83626570, E-mail: (YFZ) and (YXY)
| | - Yong-Xiang Yi
- Correspondence to: Yu-Feng Zhang and Yong-Xiang Yi, Department of Hepatopancreatobiliary Surgery, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, No. 1 Zhongfu Road, Nanjing, Jiangsu 210003, China. Tel/Fax: +86-25-83626570, E-mail: (YFZ) and (YXY)
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9
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Impact of Portal Vein Thrombosis on Endoscopic Variceal Band Ligation in Liver Cirrhosis. JOURNAL OF HEALTHCARE ENGINEERING 2021. [DOI: 10.1155/2021/9929333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background. Portal vein (PV) thrombosis (PVT) is a common complication of liver cirrhosis and can refer to thrombosis within the PV that can extend to its left or right branches and in some cases to the superior mesenteric vein or the splenic vein (Chawla and Bodh, 2015). For severe PVT patients, there are possibilities of increasing PV resistance and reduction of the blood flow though PV towards liver, which exacerbate liver function damage meanwhile elevating the gastrointestinal variceal bleeding risk. Endoscopic Variceal band ligation (EVL) is often used to prevent esophageal variceal bleeding; postoperative complications such as severe gastrointestinal bleeding and bleeding-related death, fever, retrosternal pain, and esophageal stenosis may appear. There was absence of the research which evaluated the impact of PVT in liver cirrhosis on the complication of endoscopic Variceal band ligation for now. We herein aimed to compare cirrhosis patients with and without PVT of recent complications after EVL. Method. We established the retrospective investigation on 144 consecutive cirrhosis patients (excluding patients with hepatocellular carcinoma and who received portal vein-systemic circulation devascularization or shunt surgery, splenectomy, hepatectomy, liver transplantation, transjugular intrahepatic portal vein stent shunt (TIPS), endoscopic varices Variceal ligation, or sclerotherapy before) who have received first endoscopic esophageal varices band ligation in Gastrointestinal Endoscopy Center of the First Affiliated Hospital, College of Medicine, ZheJiang University, between January 2014 and December 2017. Portal vein Doppler ultrasonography, liver computerized tomography (CT), and angiography or liver-enhanced magnetic resonance imaging (MRI) were applied to evaluate the portal vein thrombosis of each patient before EVL. There were 18 patients confirmed with portal vein thrombosis while the other 126 patients without PVT. The primary end point for this research is the upper gastrointestinal hemorrhage and related death occurred from the date of ligation until leaving hospital, and the secondary end point is the appearance of postoperative fever and retrosternal pain. Results. There are no significant differences of gastrointestinal bleeding, bleeding-related death, fever, or retrosternal pain after EVL and the length of hospital stays between cirrhotic patients with or without PVT (
). Conclusion. Liver cirrhosis with portal vein thrombosis did not increase incidence of recent complications of the endoscopic Variceal band ligation.
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10
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Ronca V, Podda GM, Cattaneo M. An "unmodifiable" risk factor that has been modified. Intern Emerg Med 2021; 16:157-159. [PMID: 31396923 DOI: 10.1007/s11739-019-02170-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 08/01/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Vincenzo Ronca
- Divisione Di Epatologia E Gastroenterologia, ASST Santi Paolo E Carlo, Università Degli Studi Di Milano, Milano, Italy
| | - Gian Marco Podda
- U.O. Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Via di Rudinì, 8, 20142, Milano, Italy.
| | - Marco Cattaneo
- U.O. Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Via di Rudinì, 8, 20142, Milano, Italy
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11
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Rugivarodom M, Charatcharoenwitthaya P. Nontumoral Portal Vein Thrombosis: A Challenging Consequence of Liver Cirrhosis. J Clin Transl Hepatol 2020; 8:432-444. [PMID: 33447527 PMCID: PMC7782107 DOI: 10.14218/jcth.2020.00067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/27/2020] [Accepted: 10/18/2020] [Indexed: 12/13/2022] Open
Abstract
Nontumoral portal vein thrombosis (PVT) is an increasingly recognized complication in patients with cirrhosis. Substantial evidence shows that portal flow stasis, complex thrombophilic disorders, and exogenous factors leading to endothelial dysfunction have emerged as key factors in the pathogenesis of PVT. The contribution of PVT to hepatic decompensation and mortality in cirrhosis is debatable; however, the presence of an advanced PVT increases operative complexity and decreases survival after transplantation. The therapeutic decision for PVT is often determined by the duration and extent of thrombosis, the presence of symptoms, and liver transplant eligibility. Evidence from several cohorts has demonstrated that anticoagulation treatment with vitamin K antagonist or low molecular weight heparin can achieve recanalization of the portal vein, which is associated with a reduction in portal hypertension-related events and improved survival in cirrhotic patients with PVT. Consequently, interest in direct oral anticoagulants for PVT is increasing, but clinical data in cirrhosis are limited. Although the most feared consequence of anticoagulation is bleeding, most studies indicate that anticoagulation therapy for PVT in cirrhosis appears relatively safe. Interestingly, the data showed that transjugular intrahepatic portosystemic shunt represents an effective adjunctive therapy for PVT in cirrhotic patients with symptomatic portal hypertension if anticoagulation is ineffective. Insufficient evidence regarding the optimal timing, modality, and duration of therapy makes nontumoral PVT a challenging consequence of cirrhosis. In this review, we summarize the current literature and provide a potential algorithm for the management of PVT in patients with cirrhosis.
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Affiliation(s)
- Manus Rugivarodom
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phunchai Charatcharoenwitthaya
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Correspondence to: Phunchai Charatcharoenwitthaya, Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Wang-Lang Road, Bangkoknoi, Bangkok 10700, Thailand. Tel: +662-419-7282, Fax: +662-411-5013, E-mail:
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12
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Zanetto A, Garcia-Tsao G. Some Answers and More Questions About Portal Vein Thrombosis in Patients With Decompensated Cirrhosis. Clin Gastroenterol Hepatol 2020; 18:2432-2434. [PMID: 32302710 PMCID: PMC11034906 DOI: 10.1016/j.cgh.2020.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/03/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Alberto Zanetto
- Digestive Disease Section, Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- VA-Connecticut Healthcare System, West Haven, CT, USA
| | - Guadalupe Garcia-Tsao
- Digestive Disease Section, Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- VA-Connecticut Healthcare System, West Haven, CT, USA
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13
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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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14
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Zhang DQ, Mu YP, Xu Y, Chen JM, Liu P, Liu W. Research Progress in Chinese Medicine Preparations for Promoting Blood Circulation and Removing Blood Stasis for Cirrhotic Patients with Portal Vein Thrombosis Following Splenectomy. Chin J Integr Med 2020; 28:855-863. [PMID: 32691285 DOI: 10.1007/s11655-020-3271-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2020] [Indexed: 02/07/2023]
Abstract
This article presented an overview of the therapeutic effects of Chinese medicine (CM) preparations for promoting blood circulation and removing blood stasis for patients with portal vein thrombosis (PVT) after splenectomy. Based on published clinical researches of CM preparations for PVT after splenectomy in patients with cirrhotic portal hypertension (CPH), this paper evaluated the incidence of PVT, and explored potential active components and mechanisms of CM preparations. Safflower Yellow Injection, Danshen Injection () Danhong Injection (), and Compound Danshen Dropping Pill () achieved good curative effect alone or combined with anticoagulant therapy. In addition, Compound Biejia Ruangan Tablet () and Anluo Huaxian Pill () can also significantly improve the hemodynamic disorders of portal vein system in patients with cirrhosis. Considering the role of CM preparations in ameliorating the incidence of PVT after splenectomy in patients with CPH, we suggested that future research should provide more attention to CM alone or CM combined with anticoagulant for cirrhosis with PVT.
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Affiliation(s)
- Ding-Qi Zhang
- Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, 201203, China
| | - Yong-Ping Mu
- Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, 201203, China
| | - Ying Xu
- Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, 201203, China
| | - Jia-Mei Chen
- Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, 201203, China
| | - Ping Liu
- Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, 201203, China
- Institute of Interdisciplinary Complex Research, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Wei Liu
- Key Laboratory of Liver and Kidney Diseases (Ministry of Education), Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
- Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, 201203, China.
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15
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Huo XX, Niu WW, Zhao YW, Zhang XL. Portal vein thrombosis with superior mesenteric venous thrombosis: A case report and review of the literature. Shijie Huaren Xiaohua Zazhi 2019; 27:1460-1464. [DOI: 10.11569/wcjd.v27.i23.1460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic variceal ligation is a first-line treatment for esophagogastric variceal bleeding patients. Portal vein thrombosis (PVT) with superior mesenteric venous thrombosis (MVT) after intensive endoscopic variceal band ligation is extremely rare.
CASE SUMMARY We report a rare case developing PVT and superior MVT after intensive endoscopic variceal band ligation. The thrombosis disappeared after full anticoagulation therapy.
CONCLUSION Our case suggested that, when ligation is required to treat esophagogastric variceal bleeding patients with a history of splenectomy caused by liver cirrhosis, especially those with chronic portal vein thrombosis, if ligation is required, too dense ligation and blocking entire blood flow should be avoided to prevent the development of PVT or MVT.
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Affiliation(s)
- Xiao-Xia Huo
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China
| | - Wei-Wei Niu
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China
| | - Yi-Wen Zhao
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China
| | - Xiao-Lan Zhang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China
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16
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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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17
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Xu X, Guo X, De Stefano V, Silva-Junior G, Goyal H, Bai Z, Zhao Q, Qi X. Nonselective beta-blockers and development of portal vein thrombosis in liver cirrhosis: a systematic review and meta-analysis. Hepatol Int 2019; 13:468-481. [PMID: 31175581 DOI: 10.1007/s12072-019-09951-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/11/2019] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis (PVT), which is associated with reduced portal vein velocity, is considered to be an indicator for worse outcomes in liver cirrhosis. Nonselective beta-blockers (NSBBs), which are widely used for primary and secondary prophylaxis of esophageal variceal bleeding in liver cirrhosis, can significantly decrease the portal vein velocity. We proposed a hypothesis that the use of NSBBs might facilitate the development of PVT in cirrhotic patients. The PubMed, EMBASE, and Cochrane Library databases were searched. Major meeting abstracts and randomized-controlled trials regarding the use of NSBBs in liver cirrhosis were also hand-searched. The number of patients who developed PVT in groups treated with or without NSBBs was pooled. Odds ratios (ORs) or risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. Subgroup meta-analyses were performed according to the type of studies, region, and study quality. Meta-regression and sensitivity analyses were performed to explore the source of heterogeneity. Nine of the 6416 retrieved papers were finally included. Overall, meta-analysis demonstrated that NSBBs were significantly associated with the development of PVT (OR 4.62, 95% CI 2.50-8.53; p < 0.00001). The heterogeneity was statistically significant (I2 = 80%; p < 0.00001). Subgroup meta-analyses still demonstrated a significantly positive association of NSBBs with the development of PVT in cohort studies (RR 2.57, 95% CI 1.46-4.51; p = 0.001) and case-control studies (OR 8.17, 95% CI 2.46-27.06; p = 0.0006). Sensitivity analyses based on subgroups find the source of heterogeneity. Based on the systematic review and meta-analysis, we found that the use of NSBBs increased a 4.62-fold risk of PVT in cirrhotic patients.
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Affiliation(s)
- Xiangbo Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China
| | - Valerio De Stefano
- Fondazione Policlinico A. Gemelli IRCCS, Istituto Di Ematologia, Università Cattolica, Rome, Italy
| | - Gilberto Silva-Junior
- Department of General Medicine and Hepatology, Quinta D'Or Hospital, Rio de Janeiro, Brazil
| | - Hemant Goyal
- Department of Internal Medicine, School of Medicine, Mercer University, Macon, GA, USA
| | - Zhaohui Bai
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Qingchun Zhao
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China.
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18
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Abstract
Gastrointestinal bleeding is one of the major causes of death in patients with cirrhosis, and gastroesophageal varices represent the main source of hemorrhage. Even though in the last decades survival has been improved because of the widespread adoption of effective treatments and optimization of general medical care, mortality is still significantly high, and decompensated patients pose a complex challenge requiring a multidisciplinary approach that is crucial to improve survival. The aims of this commentary are to review the most recent advances in the management of esophageal variceal bleeding and to highlight useful information to aid hepatologists in clinical practice.
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Affiliation(s)
- Alberto Zanetto
- Digestive Disease Section, Yale University School of Medicine, 333 Cedar Street 1080 LMP New Haven, Connecticut, 06520-8019, USA.,VA-CT Healthcare System, 950 Campbell Ave, West Haven, Connecticut, 06516, USA
| | - Guadalupe Garcia-Tsao
- Digestive Disease Section, Yale University School of Medicine, 333 Cedar Street 1080 LMP New Haven, Connecticut, 06520-8019, USA.,VA-CT Healthcare System, 950 Campbell Ave, West Haven, Connecticut, 06516, USA
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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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Lv Y, Qi X, He C, Wang Z, Yin Z, Niu J, Guo W, Bai W, Zhang H, Xie H, Yao L, Wang J, Li T, Wang Q, Chen H, Liu H, Wang E, Xia D, Luo B, Li X, Yuan J, Han N, Zhu Y, Xia J, Cai H, Yang Z, Wu K, Fan D, Han G. Covered TIPS versus endoscopic band ligation plus propranolol for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis: a randomised controlled trial. Gut 2018; 67:2156-2168. [PMID: 28970291 DOI: 10.1136/gutjnl-2017-314634] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/18/2017] [Accepted: 08/21/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Limited data are available on the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis (PVT). This study aimed to compare transjugular intrahepatic portosystemic shunt (TIPS) with covered stents versus endoscopic band ligation (EBL) plus propranolol for the prevention of variceal rebleeding among patients with cirrhosis and PVT. DESIGN Consecutive cirrhotic patients (94% Child-Pugh class A or B) with PVT who had variceal bleeding in the past 6 weeks were randomly assigned to TIPS group (n=24) or EBL plus propranolol group (EBL+drug, n=25), respectively. Primary endpoint was variceal rebleeding. Secondary endpoints included survival, overt hepatic encephalopathy (OHE), portal vein recanalisation and rethrombosis, other complications of portal hypertension and adverse events. RESULTS During a median follow-up of 30 months in both groups, variceal rebleeding was significantly less frequent in the TIPS group (15% vs 45% at 1 year and 25% vs 50% at 2 years, respectively; HR=0.28, 95% CI 0.10 to 0.76, p=0.008), with a significantly higher portal vein recanalisation rate (95% vs 70%; p=0.03) and a relatively lower rethrombosis rate (5% vs 33%; p=0.06) compared with the EBL+drug group. There were no statistically significant differences in survival (67% vs 84%; p=0.152), OHE (25% vs 16%; p=0.440), other complications of portal hypertension and adverse events between groups. CONCLUSION Covered TIPS placement in patients with PVT and moderately decompensated cirrhosis was more effective than EBL combined with propranolol for the prevention of rebleeding, with a higher probability of PVT resolution without increasing the risk of OHE and adverse effects, but this benefit did not translate into improved survival. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT01326949.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xingshun Qi
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Chuangye He
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | | | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Hongbo Zhang
- Department of Digestive Endoscopy, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Huahong Xie
- Department of Digestive Endoscopy, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Liping Yao
- Department of Digestive Endoscopy, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jianhong Wang
- Department of Ultrasound, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Tao Li
- Department of Ultrasound, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Hui Chen
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Haibo Liu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Enxing Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Dongdong Xia
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Na Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Ying Zhu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jielai Xia
- Department of Medical Statistics, Fourth Military Medical University, Xi'an, China
| | - Hongwei Cai
- Department of Medical Statistics, Fourth Military Medical University, Xi'an, China
| | - Zhiping Yang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kaichun Wu
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Hypercoagulability in End-stage Liver Disease: Review of Epidemiology, Etiology, and Management. Transplant Direct 2018; 4:e403. [PMID: 30534594 PMCID: PMC6233657 DOI: 10.1097/txd.0000000000000843] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 09/23/2018] [Indexed: 12/14/2022] Open
Abstract
In this review, we analyze the epidemiology of thromboses related to end-stage liver disease (ESLD), discuss causes of hypercoagulability, describe susceptible populations, and critically evaluate proposed prophylaxis and treatment of thromboses. Classically, ESLD has been regarded as a model for coagulopathy, and patients were deemed to be at high risk for bleeding complications. Patients with ESLD are not auto-anticoagulated, and they do not have a lower risk of portal vein thrombosis, intracardiac thrombus formation, pulmonary embolism or hepatic artery thrombosis. Though the cause of hypercoagulability is multifactorial, endothelial dysfunction likely plays a central role for all patients with ESLD. Some subpopulations, such as patients with nonalcoholic steatohepatitis and autoimmune conditions, are at increased risk of thrombotic events as are patients of Hispanic ethnicity. The science behind prophylaxis of different types of clotting and treatment of thromboses is developing rapidly. A number of medications, including low molecular weight heparin, unfractionated heparin, aspirin, vitamin K antagonists, and direct oral anticoagulants can be used, but clear guidelines are lacking. Acute intraoperative clotting can be associated with high mortality. Routine use of transesophageal echocardiography can be helpful in early recognition and treatment of intraoperative thrombosis. Heparin should be reserved for cases of intracardiac thrombus/pulmonary embolism without hemodynamic instability. In unstable patients, low dose of recombinant tissue plasminogen activator can be used. In this new era of heightened awareness of thrombotic events in ESLD patients, prospective randomized trials are urgently needed to best guide clinical practice.
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Gîrleanu I, Trifan A, Stanciu C, Sfarti C. Portal vein thrombosis in cirrhotic patients - it is always the small pieces that make the big picture. World J Gastroenterol 2018; 24:4419-4427. [PMID: 30356984 PMCID: PMC6196341 DOI: 10.3748/wjg.v24.i39.4419] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/02/2018] [Accepted: 10/05/2018] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) is a frequent and serious complication in patients with liver cirrhosis (LC). Recently, a new classification of PVT was proposed, although the functional component was not completed included. The status of liver disease (compensated/decompensated) should be added to this classification. Reduced portal flow velocity and the acquired hypercoagulable status associated with LC are the main risk factors for PVT development, although endothelial dysfunction may play an important role that needs to be further evaluated. The European Association for the Study of the Liver and the American Association for the Study of Liver Disease recommend that the anticoagulant treatment should be consider in cirrhotic patients with PVT. Low molecular weight heparin and vitamin K antagonists proved their efficacy and relatively safety in PVT treatment, although in addition to recanalization rates, more complex end-points such as mortality and decompensation rate should be evaluated. The new oral anticoagulant therapies offers the advantage of oral administration in the absence of laboratory monitoring, however, there are a few reports regarding their use in cirrhotic patients, most of them referring to compensated isolated cases. Transjugular intrahepatic portosystemic shunt could be an alternative if thrombosis progresses despite anticoagulatant therapy and/or when PVT is associated with portal hypertension complications. The aim of this editorial is to discuss the different aspects of pathophysiology, clinical relevance, diagnosis and management of PVT in patients with LC.
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Affiliation(s)
- Irina Gîrleanu
- Department of Gastroenterology, “Grigore T Popa” University of Medicine and Pharmacy, Iași 700115, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, Iași 700115, Romania
| | - Anca Trifan
- Department of Gastroenterology, “Grigore T Popa” University of Medicine and Pharmacy, Iași 700115, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, Iași 700115, Romania
| | - Carol Stanciu
- Department of Gastroenterology, “Grigore T Popa” University of Medicine and Pharmacy, Iași 700115, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, Iași 700115, Romania
| | - Cătălin Sfarti
- Department of Gastroenterology, “Grigore T Popa” University of Medicine and Pharmacy, Iași 700115, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, Iași 700115, Romania
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Senzolo M, Riva N, Dentali F, Rodriguez-Castro K, Sartori MT, Bang SM, Martinelli I, Schulman S, Alatri A, Beyer-Westendorf J, Di Minno MND, Ageno W. Long-Term Outcome of Splanchnic Vein Thrombosis in Cirrhosis. Clin Transl Gastroenterol 2018; 9:176. [PMID: 30108204 PMCID: PMC6092393 DOI: 10.1038/s41424-018-0043-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/07/2018] [Accepted: 06/16/2018] [Indexed: 02/06/2023] Open
Abstract
Introduction Little is known about the long-term outcome of cirrhotic patients with splanchnic vein thrombosis (SVT). This prospective cohort study aimed to describe the clinical presentation, bleeding incidence, thrombotic events, and mortality in patients with SVT associated with cirrhosis. Methods Among 604 consecutive patients with SVT enrolled over 2 years, 149 had cirrhosis. Major bleeding, thrombotic events, and all-cause mortality were recorded during a 2-year follow-up. In a subgroup, the degree of recanalization with or without anticoagulation therapy, and the correlation between clinical events and liver disease severity were also investigated. Results The most common thrombosis sites were the portal (88%) and mesenteric veins (34%). At presentation, 50% of patients were asymptomatic. Anticoagulation was administered to 92/149 patients for a median of 6.5 months. Vessel recanalization was documented in 47/98 patients with a radiological follow-up. Anticoagulation was associated with a 3.33-fold higher of recanalization rate, and a lower recurrent thrombosis rate, while patients with and without anticoagulation experienced a similar rate of major bleeding episodes. Mortality rates were 6.8 per 100 patient-years for patients with thrombosis completely or partially resolving during the follow-up, and 15.4 per 100 patient-years for those with stable or progressing thrombosis. An impact of SVT on survival was only apparent in patients with more advanced liver disease (Child–Pugh B-C). Conclusions Patients with SVT and cirrhosis have a substantial long-term risk of recurrent thrombotic events, which is reduced by anticoagulation therapy without any increase in bleeding risk. Anticoagulation can improve the likelihood of vessel recanalization, and is associated with a lower risk of death for decompensated patients.
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Affiliation(s)
- Marco Senzolo
- Multivisceral Transplant Unit, University Hospital of Padua, Padua, Italy.
| | - Nicoletta Riva
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | | | - Maria Teresa Sartori
- Clinical Medicine I, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ida Martinelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Adriano Alatri
- Hemostasis and Thrombosis Center, A.O. Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Jan Beyer-Westendorf
- Thrombosis Research, Department of Medicine, 1st Division of Hematology, Dresden University Clinic, Dresden, Germany
| | | | - Walter Ageno
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
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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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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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Cruz-Ramón V, Chinchilla-López P, Ramírez-Pérez O, Méndez-Sánchez N. Effects of Portal Vein Thrombosis on the Outcomes of Liver Cirrhosis: A Mexican Perspective. J Transl Int Med 2017; 5:189-191. [PMID: 29340273 PMCID: PMC5767706 DOI: 10.1515/jtim-2017-0031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Vania Cruz-Ramón
- Liver Research Unit, Medica Sur Clinic & Foundation, Mexico City, Mexico
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Stine JG, Northup PG. Coagulopathy Before and After Liver Transplantation: From the Hepatic to the Systemic Circulatory Systems. Clin Liver Dis 2017; 21:253-274. [PMID: 28364812 DOI: 10.1016/j.cld.2016.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The hemostatic environment in patients with cirrhosis is a delicate balance between prohemostatic and antihemostatic factors. There is a lack of effective laboratory measures of the hemostatic system in patients with cirrhosis. Many are predisposed to pulmonary embolus, deep vein thrombosis, and portal vein thrombosis in the pretransplantation setting. This pretransplantation hypercoagulable milieu seems to extend for at least several months post-transplantation. Patients with nonalcoholic fatty liver disease, inherited thrombophilia, portal hypertension in the absence of cirrhosis, and hepatocellular carcinoma often require individualized approach to anticoagulation. Early reports suggest a potential role for low-molecular-weight heparins and direct-acting anticoagulants.
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Affiliation(s)
- Jonathan G Stine
- Center for the Study of Coagulation Disorders in Liver Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, 1215 JPA and Lee Street, Charlottesville, VA 22908, USA
| | - Patrick G Northup
- Center for the Study of Coagulation Disorders in Liver Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, 1215 JPA and Lee Street, Charlottesville, VA 22908, USA.
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Gulamhusein AF, Kamath PS. The epidemiology and pathogenesis of gastrointestinal varices. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Diagnosis and treatment guidelines for aberrant portal hemodynamics: The Aberrant Portal Hemodynamics Study Group supported by the Ministry of Health, Labor and Welfare of Japan. Hepatol Res 2017; 47:373-386. [PMID: 28058764 DOI: 10.1111/hepr.12862] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 12/29/2016] [Accepted: 01/04/2017] [Indexed: 12/18/2022]
Abstract
Idiopathic portal hypertension (IPH), causing aberrant portal hemodynamics, is a disease with an as yet unidentified cause and no established treatment protocol. The Japanese research group on IPH in Japan was set up in 1975 by the Ministry of Health, Labor and Welfare. Extrahepatic portal obstruction and Budd-Chiari syndrome (BCS) have since been added to the group's research subjects. The aims of the research group are to accurately evaluate the current status of the three diseases in Japan, elucidate their etiology and pathogenesis, and develop new treatments. Due to the long-term efforts of the Japanese research group, aberrant portal hemodynamics has been investigated in a variety of aspects, from epidemiological and pathological studies to molecular biology analyses. As a result, it has been shown that there are abnormal genes in the liver, specific for IPH. In addition, pathological findings of BCS were internationally compared and the difference in findings between Japan and Europe (or North America) has been clarified. Furthermore, it was found that complication rates of hepatocellular carcinoma in BCS were higher in Japan. Based on the research, "Diagnosis and treatment of aberrant portal hemodynamics (2001)", including diagnostic criteria for aberrant portal hemodynamics, was published in 2001. In 2013, it was revised to "Diagnosis and treatment guidelines for aberrant portal hemodynamics (2013)" after the incorporation of diagnosis and treatment in accordance with its current status.
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Abstract
BACKGROUND Portal vein thrombosis (PVT) is a complication of cirrhosis. However, whether PVT worsens cirrhosis outcome is a debated issue. AIM To report an update on the management of PVT. METHODS A review was performed on the outcome, prevention, and treatment of PVT. RESULTS Some studies suggest that PVT could worsen the rate of hepatic decompensation and survival of cirrhosis, whereas others report a non-negative impact of PVT in the outcome of cirrhosis. Therefore, the prognostic value of PVT in cirrhosis remains a gray zone. One single randomized-controlled trial reported that enoxaparin could prevent PVT, delay the occurrence of hepatic decompensation, and improve survival. However, no further study data confirmed this assumption and the issue is not actually generalizable. Numerous studies report that anticoagulation determines a relatively high rate of portal vein recanalization in cirrhotics PVT. However, further data are warranted to confirm the risk-to-benefit of anticoagulation, especially bleeding. Transjugular intrahepatic portosystemic shunt (TIPS) has been reported to be effective as a treatment of PVT in cirrhosis, with the advantage of avoiding the risk of bleeding linked to anticoagulation. However, there are no data comparing TIPS with anticoagulation as a treatment of PVT in cirrhosis. Furthermore, there is no evidence on whether both anticoagulation and TIPS improve survival. CONCLUSION It is uncertain whether PVT affects cirrhosis outcome. Further data are needed to weigh the risk/benefit ratio of enoxaparin for the prevention of PVT in cirrhosis. Anticoagulation or TIPS should probably be indicated in liver transplantation candidates, but avoided in patients not suitable for liver transplantation and with an otherwise poor prognosis. Future studies should evaluate which subgroup of cirrhotics with PVT may benefit from treatment. Management of PVT in cirrhosis should be personalized.
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Qi X, Su C, Ren W, Yang M, Jia J, Dai J, Xu W, Guo X. Association between portal vein thrombosis and risk of bleeding in liver cirrhosis: A systematic review of the literature. Clin Res Hepatol Gastroenterol 2015; 39:683-91. [PMID: 25956490 DOI: 10.1016/j.clinre.2015.02.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 01/29/2015] [Accepted: 02/21/2015] [Indexed: 02/07/2023]
Abstract
AIMS A systematic review of the literature was conducted to explore the association of portal vein thrombosis (PVT) with the risk of bleeding in liver cirrhosis. METHODS PubMed, EMBASE, and Cochrane library databases were searched for all relevant papers, which compared the prevalence of bleeding at baseline and/or incidence of bleeding during follow-up between cirrhotic patients with and without PVT. RESULTS Eighteen papers were eligible for this systematic review. The heterogeneity among studies was marked with regards to the treatment modalities, sources of bleeding, lengths of follow-up, and ways of data expression. But most of their findings were homozygous and suggested that the cirrhotic patients with PVT were more likely to have previous histories of bleeding at their admission and to develop de novo bleeding and/or rebleeding during the short- and long-term follow-up. The association of PVT with the risk of bleeding might be weakened in the multivariate analyses. Additionally, as for the cirrhotic patients with gastric variceal bleeding treated with medical/endoscopic therapy, the association of PVT with the risk of rebleeding remained controversial in 2 studies; as for the cirrhotic patients undergoing transjugular intrahepatic portosystemic shunts for the management of variceal bleeding, a pre-existing PVT was not associated with the risk of rebleeding. CONCLUSIONS Based on a systematic review of the literature, there was a positive association between the presence of PVT and risk of bleeding in liver cirrhosis in most of clinical conditions. However, whether PVT aggravated the development of bleeding during follow-up needed to be further explored.
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Affiliation(s)
- Xingshun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China; Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China.
| | - Chunping Su
- Library of Fourth Military Medical University, Xi'an 710032, China
| | - Weirong Ren
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Digestive Diseases, Sanmenxia Central Hospital, Henan University of Science and Technology, Xiaoshan Road, Sanmenxia 472000, China
| | - Man Yang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Gastroenterology, Songgang People's Hospital, Shenzhen 518105, China
| | - Jia Jia
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Digestive Diseases, Shaanxi Provincial People's Hospital, Xi'an 710068, China
| | - Junna Dai
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China
| | - Wenda Xu
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China.
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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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Qi X, De Stefano V, Li H, Dai J, Guo X, Fan D. Anticoagulation for the treatment of portal vein thrombosis in liver cirrhosis: a systematic review and meta-analysis of observational studies. Eur J Intern Med 2015; 26:23-9. [PMID: 25566699 DOI: 10.1016/j.ejim.2014.12.002] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 12/03/2014] [Accepted: 12/09/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Systematic review and meta-analysis were performed to evaluate the safety and efficacy of anticoagulation for the treatment of portal vein thrombosis (PVT) in cirrhotic patients. METHODS The PubMed, EMBASE, Cochrane Library, and ScienceDirect databases were searched. The rates of bleeding complications and portal vein recanalization in patients who received anticoagulant therapy were pooled. The odds ratio (OR) with 95% confidence interval (CI) was calculated to express the difference in the rate of portal vein recanalization between anticoagulation and non-anticoagulation groups. All meta-analyses were conducted by using a random-effects model. RESULTS Sixteen of 960 initially identified papers were included. Two studies reported a low incidence of major anticoagulation-related complications (4% [2/55] and 3% [1/33]), but no lethal complications occurred. The rate of anticoagulation-related bleeding ranged from 0% to 18% with a pooled rate of 3.3% (95% CI=1.1%-6.7%). The heterogeneity was not significant in the meta-analysis. The total rate of portal vein recanalization ranged from 37% to 93% with a pooled rate of 66.6% (95% CI=54.7%-77.6%). The rate of complete portal vein recanalization ranged from 0% to 75% with a pooled rate of 41.5% (95% CI=29.2%-54.5%). However, the heterogeneity was significant in the 2 meta-analyses. The rate of complete portal vein recanalization was significantly higher in anticoagulation group than in non-anticoagulation group (OR=4.16, 95% CI=1.88-9.20, P=0.0004). The heterogeneity was not significant in the meta-analysis. CONCLUSION Anticoagulation could achieve a relatively high rate of portal vein recanalization in cirrhotic patients with PVT. Given that only a small number of non-randomized comparative studies are reported, randomized controlled trials are warranted to confirm the risk-to-benefit of anticoagulation in such patients, especially anticoagulation-related bleeding.
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Affiliation(s)
- Xingshun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China; Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
| | | | - Hongyu Li
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
| | - Junna Dai
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
| | - Daiming Fan
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
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