1
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Huang J, Liu H. Portal venous blood flow velocity is a factor associated with portal venous thrombosis after partial splenic artery embolization in hepatic cirrhosis patients. Ann Med Surg (Lond) 2024; 86:650-654. [PMID: 38333286 PMCID: PMC10849375 DOI: 10.1097/ms9.0000000000001577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/22/2023] [Indexed: 02/10/2024] Open
Abstract
Objective To investigate risk factors for portal venous thrombosis (PVT) after partial splenic artery embolization (PSE) in hepatic cirrhosis patients. Methods The authors retrospectively analyzed 151 hepatic cirrhosis patients with hypersplenism who underwent partial splenic artery embolization between January 2020 and December 2021. The patients were divided into a PVT group and a non-PVT group according to whether they had PVT after PSE. Univariate analyses were performed to select risk factors for PVT after PSE, and multivariate analysis was used to analyze variates with a value of P less than 0.1 in univariate analysis. Results There were 151 patients enroled in the study, with 22 patients in the PVT group and 129 patients in the non-PVT group. There was no significant difference in terms of age, sex, smoking, hypertension, diabetes, Child-Pugh between two groups. White blood cell (WBC) and platelet counts after PSE were significantly higher than those before PSE in both the PVT group and non-PVT group. Univariate analysis showed that portal venous blood flow velocity, ligation of oesophageal varices and WBC after PSE were found to have a P value less than 0.1. Multivariate analysis showed that portal venous blood flow velocity was a factor associated with PVT after PSE. Conclusion Portal venous blood flow velocity was a factor associated with PVT after PSE. Portal venous blood flow velocity should be considered before patients undergo PSE.
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Affiliation(s)
- Jiaming Huang
- Department of Gastroenterology, Ganzhou People’s Hospital
| | - Haifeng Liu
- Department of Gastroenterology, Xinfeng People’s Hospital, Ganzhou, Jiangxi, China
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2
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Guerrero A, Campo LD, Piscaglia F, Scheiner B, Han G, Violi F, Ferreira CN, Téllez L, Reiberger T, Basili S, Zamora J, Albillos A. Anticoagulation improves survival in patients with cirrhosis and portal vein thrombosis: The IMPORTAL competing-risk meta-analysis. J Hepatol 2023; 79:69-78. [PMID: 36858157 DOI: 10.1016/j.jhep.2023.02.023] [Citation(s) in RCA: 18] [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: 06/29/2022] [Revised: 01/19/2023] [Accepted: 02/13/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND & AIMS Previous meta-analyses demonstrated the safety and efficacy of anticoagulation in the recanalization of portal vein thrombosis in patients with cirrhosis. Whether this benefit translates into improved survival is unknown. We conducted an individual patient data (IPD) meta-analysis to assess the effect of anticoagulation on all-cause mortality in patients with cirrhosis and portal vein thrombosis. METHODS In this IPD meta-analysis, we selected studies comparing anticoagulation vs. no treatment in patients with cirrhosis and portal vein thrombosis from PubMed, Embase, and Cochrane databases (until June 2020) (PROSPERO no.: CRD42020140026). IPD were subsequently requested from authors. The primary outcome - the effect of anticoagulation on all-cause mortality - was assessed by a one-step meta-analysis based on a competing-risk model with liver transplantation as the competing event. The model was adjusted for clinically relevant confounders. A multilevel mixed-effects logistic regression model was used to determine the effect of anticoagulation on recanalization. RESULTS Individual data on 500 patients from five studies were included; 205 (41%) received anticoagulation and 295 did not. Anticoagulation reduced all-cause mortality (adjusted subdistribution hazard ratio 0.59; 95% CI 0.49-0.70), independently of thrombosis severity and recanalization. The effect of anticoagulation on all-cause mortality was consistent with a reduction in liver-related mortality. The recanalization rate was higher in the anticoagulation arm (adjusted odds ratio 3.45; 95% CI 2.22-5.36). The non-portal-hypertension-related bleeding rate was significantly greater in the anticoagulation group. CONCLUSIONS Anticoagulation reduces all-cause mortality in patients with cirrhosis and portal vein thrombosis independently of recanalization, but at the expense of increasing non-portal hypertension-related bleeding. PROSPERO REGISTRATION NUMBER CRD42020140026. IMPACT AND IMPLICATIONS Anticoagulation is effective in promoting recanalization of portal vein thrombosis in patients with cirrhosis, but whether this benefit translates into improved survival is controversial. Our individual patient data meta-analysis based on a competing-risk model with liver transplantation as the competing event shows that anticoagulation reduces all-cause mortality in patients with cirrhosis and portal vein thrombosis independently of recanalization. According to our findings, portal vein thrombosis may identify a group of patients with cirrhosis that benefit from long-term anticoagulation.
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Affiliation(s)
- Antonio Guerrero
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto Salud Carlos III, Madrid, Spain
| | - Laura Del Campo
- Unidad de Bioestadística Clínica. Hospital Universitario Ramón y Cajal. Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Fabio Piscaglia
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero Universitaria di Bologna, Italy
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna. Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, Xi'an International Medical Center Hospital, Digestive Diseases Hospital, Northwest University, Xi'an, China; Department of Liver Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Francesco Violi
- Department of Internal Medicine, Anestesiology and Cardiovascular Sciences, Sapienza University, Roma, Italy
| | - Carlos-Noronha Ferreira
- Servico de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Clinica Universitaria de Gastrenterologia, Facultad de Medicina, Lisbon, Portugal
| | - Luis Téllez
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto Salud Carlos III, Madrid, Spain
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna. Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
| | - Stefania Basili
- Department of Internal Medicine, Anestesiology and Cardiovascular Sciences, Sapienza University, Roma, Italy
| | - Javier Zamora
- Unidad de Bioestadística Clínica. Hospital Universitario Ramón y Cajal. Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Institute of Metabolism and Systems Research, University of Birmingham, United Kingdom
| | - Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto Salud Carlos III, Madrid, Spain.
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3
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Yao C, Zhao M, Ibrahim B, Saab S. Anticoagulation for the Treatment of Portal Vein Thrombosis in Cirrhosis: A Systematic Review and Meta-Analysis of Comparative Studies. J Clin Exp Hepatol 2023; 13:404-413. [PMID: 37250883 PMCID: PMC10213860 DOI: 10.1016/j.jceh.2022.12.016] [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] [Received: 05/30/2022] [Revised: 12/13/2022] [Accepted: 12/24/2022] [Indexed: 05/31/2023] Open
Abstract
Background Portal vein thrombosis (PVT) leads to significant morbidity and mortality burden in patients with cirrhosis. An improved understanding of the utility of anticoagulation in patients with PVT will aid clinical decision making and inform future research. This meta-analysis aimed to evaluate the association between anticoagulation therapy and clinical outcomes in the context of treatment for PVT in cirrhosis. Methods Pubmed, Embase, and Web of Science were searched from inception to February 13, 2022, for studies comparing the use of anticoagulation to other modalities as treatment for PVT in cirrhosis. Pooled odds ratios (OR) were calculated using a random-effects model for PVT improvement, recanalization, progression, bleeding events, and all-cause mortality in treatment studies. Results We identified 944 records, of which 16 studies (n = 1126) examining anticoagulation as PVT treatment were included for subsequent analysis. Anticoagulation as PVT treatment was associated with PVT improvement (OR 3.64; 95% CI 2.56-5.17), PVT recanalization (OR 3.73; 95% CI 2.45-5.68), decreased PVT progression (OR 0.38; 95% CI 0.23-0.63), and decreased all-cause mortality (OR 0.47; 95% CI 0.29-0.75). The use of anticoagulation was not associated with bleeding events (OR 0.80; 95% CI 0.39-1.66). All analyses demonstrated low heterogeneity. Conclusions These results support the use of anticoagulation in cirrhosis as treatment for PVT. These findings may inform the clinical management of PVT and highlight the need for further studies such as large randomized controlled trials characterizing the safety and efficacy of anticoagulation for PVT in cirrhosis.
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Affiliation(s)
- Calvin Yao
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Matthew Zhao
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Brittney Ibrahim
- Departments of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
- Departments of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
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4
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Prakash S, Bies J, Hassan M, Mares A, Didia SC. Portal vein thrombosis in cirrhosis: A literature review. Front Med (Lausanne) 2023; 10:1134801. [PMID: 37181351 PMCID: PMC10169608 DOI: 10.3389/fmed.2023.1134801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/03/2023] [Indexed: 05/16/2023] Open
Abstract
Portal Vein Thrombosis (PVT), a common complication of advanced liver disease, is defined as an obstruction of the portal vein due to thrombus formation that can extend to the superior mesenteric and splenic veins. It was believed that PVT occurred predominantly due to prothrombotic potential. However, recent studies have shown that decreased blood flow related to portal hypertension appears to increase PVT risk as per Virchow's triad. It is well known that there is a higher incidence of PVTs in cirrhosis with a higher MELD and Child Pugh score. The controversy for management of PVTs in cirrhotics lies in the individualized assessment of risks versus benefits of anticoagulation, since these patients have a complex hemostatic profile with both bleeding and procoagulant propensities. In this review, we will systematically compile the etiology, pathophysiology, clinical features, and management of portal vein thrombosis in cirrhosis.
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Affiliation(s)
- Swathi Prakash
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Jared Bies
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Mariam Hassan
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Adriana Mares
- Paul L. Foster School of Medicine, El Paso, TX, United States
| | - S. Claudia Didia
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
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5
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Evaluation of Low-Molecular-Weight Heparin for Treatment of Portal Vein Thrombosis in Liver Cirrhosis Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020292. [PMID: 36837493 PMCID: PMC9965161 DOI: 10.3390/medicina59020292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/29/2023] [Accepted: 02/01/2023] [Indexed: 02/08/2023]
Abstract
Background and Objectives: Even though low-molecular-weight heparin (LMWH), including dalteparin, has a critical role in portal vein thrombosis (PVT) treatment in liver cirrhosis (LC) patients, the predictive factors and the proper dose of dalteparin for PVT treatment and relapse have not yet been investigated. Materials and Methods: This retrospective study evaluated the records of LC patients receiving dalteparin from July 2013 to June 2019. The odds ratio (OR) and adjusted OR were calculated from univariate and multivariable analyses, respectively. Results: Among data from 121 patients, the overall recanalization rate of all patients was 66.1% (80 patients). No history of variceal bleeding (OR 4.6, 95% CI: 1.88-11.43) and the case of newly developed thrombus before dalteparin treatment (OR 3.2, 95% CI: 1.24-8.08) were predictive factors associated with increased treatment response. Relapse of PVT occurred in 32 out of 80 patients (40%) who showed a recanalization. The risk of relapse was 3.1-3.9 times higher in those who took more than three months or more than six months from the diagnosis of PVT to dalteparin treatment compared to those who took less than these durations, respectively. In the dosing regimen, patients with the kg-based dosing regimen showed 2.6 times better response than those with the fixed dosing regimen. However, no difference in bleeding complications was observed. Conclusion: In the dosing regimen, the kg-based regimen that was the same as the venous thromboembolism regimen was a better option for the efficacy and safety of dalteparin therapy. Additionally, when treating PVT in LC patients, careful monitoring is recommended for patients with predictive factors for treatment response and relapse of PVT.
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6
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Ma J, Chalasani NP, Schwantes-An L, Björnsson ES. Review article: the safety of anticoagulants and antiplatelet agents in patients with cirrhosis. Aliment Pharmacol Ther 2023; 57:52-71. [PMID: 36373544 DOI: 10.1111/apt.17297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/26/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
Patients with cirrhosis were long thought to be coagulopathic. However, this paradigm has changed in recent years and currently, cirrhosis is recognised as a prothrombotic state. Due to the increasing incidence of cirrhosis from nonalcoholic steatohepatitis which is closely associated with cardiac disease, patients with cirrhosis increasingly require therapy with anticoagulants and antiplatelet agents. However, their potential for causing catastrophic and life-threatening bleeding in patients with cirrhosis leads to hesitancy about their use in patients with cirrhosis. Overall, traditional anticoagulation is safe for all Child-Pugh classes while newer direct oral anticoagulants (DOACs) are mostly safe in Child-Pugh class A/B and contraindicated in severe hepatic impairment. For different indications, published data to date suggest that anticoagulation is overall safe for patients with cirrhosis who have venous thromboembolism, atrial fibrillation and portal vein thrombosis, and does not increase the risk of variceal bleeding. Moreover, DOACs appear to have similar safety profiles as traditional anticoagulants. Finally, most studies suggest that antiplatelet agents are also safe to use in patients with cirrhosis although they are mostly contraindicated in severe hepatic impairment. For both anticoagulants and antiplatelet agents, severe thrombocytopaenia presents a relative contraindication to their use. More prospective trials and large cohort studies are needed to advance our understanding of the safety and nuances of DOACs and antiplatelet agents in patients with advanced cirrhosis.
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Affiliation(s)
- Jiayi Ma
- Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - Naga P Chalasani
- Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - Linus Schwantes-An
- Indiana University School of Medicine, Medical & Molecular Genetics, Indianapolis, Indiana, USA
| | - Einar Stefán Björnsson
- Department of Gastroenterology, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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7
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Lu H, Zheng C, Xiong B, Xia X. Efficacy and safety of heparin plus dexamethasone after partial splenic embolization for liver cirrhosis with massive splenomegaly. BMC Gastroenterol 2022; 22:470. [PMID: 36402985 PMCID: PMC9675231 DOI: 10.1186/s12876-022-02580-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/15/2022] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The aim of this study was to investigate the efficacy and safety of the combination of low-molecular-weight heparin + dexamethasone after partial splenic embolization in cirrhotic patients with massive splenomegaly. METHODS This study included 116 patients with liver cirrhosis complicated with massive splenomegaly who underwent PSE in Union Hospital from January 2016 to December 2019, and they met the criteria. They were divided into two groups: PSE + Hep + Dex group (N = 54) and PSE group (N = 62). We conducted a retrospective study to analyze the efficacy and safety of the two groups of patients. RESULTS The volume of splenic embolization was 622.34 ± 157.06 cm3 in the PSE + Hep + DEX group and 587.62 ± 175.33 cm3 in the PSE group (P = 0.306). There was no statistically difference in the embolization rate of the spleen between the two groups (P = 0.573). WBC peaked 1 week after PSE and PLT peaked 1 month after PSE in both groups; it gradually decreased later, but was significantly higher than the preoperative level during the 12-month follow-up period. The incidences of abdominal pain (46.3% vs 66.1%, P = 0.039), fever (38.9% vs 75.8%, P < 0.001), PVT (1.9% vs 12.9%, P = 0.026), refractory ascites (5.6% vs 19.4%, P = 0.027) were lower in the PSE + Hep + DEX group than in the PSE group. The VAS score of abdominal pain in PSE group was higher than that in PSE + Hep + DEX group on postoperative days 2-8 (P < 0.05). Splenic abscess occurred in 1(1.6%) patient in the PSE group and none (0.0%) in the PSE + Hep + DEX group (P = 0.349). CONCLUSIONS The combined use of dexamethasone and low-molecular-weight heparin after PSE is a safe and effective treatment strategy that can significantly reduce the incidence of complications after PSE (such as post-embolization syndrome, PVT, refractory ascites).
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Affiliation(s)
- Haohao Lu
- grid.33199.310000 0004 0368 7223Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022 China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022 China
| | - Chuansheng Zheng
- grid.33199.310000 0004 0368 7223Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022 China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022 China
| | - Bin Xiong
- grid.33199.310000 0004 0368 7223Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022 China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022 China
| | - Xiangwen Xia
- grid.33199.310000 0004 0368 7223Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022 China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022 China
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8
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Zhang Z, Zhao Y, Han B, Zhu Z, Sun L, Cui X. The Efficacy and Safety of Anticoagulants in the Treatment of Cirrhotic Portal Vein Thrombosis: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2022; 28:10760296221104797. [PMID: 35656719 PMCID: PMC9168872 DOI: 10.1177/10760296221104797] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To evaluate the efficacy and safety of anticoagulant therapy in patients with
cirrhotic PVT, and compare differences in efficacy and safety among
different anticoagulants. Methods We comprehensively searched Pubmed, Cochrane Library, EMBASE, and
ClinicalTrials.gov from inception to April 2022 for studies using
anticoagulants for cirrhotic PVT. Meta-analysis was performed to calculate
odds ratios (ORs) with 95% confidence intervals (CIs). Results 3 RCTs and 14 cohort studies involving 1270 patients were included.
Anticoagulant therapy can increase the recanalization rate compared with
non-anticoagulation therapy (OR 4.44, 95% CI 3.11-6.32,
I2 = 2.5%) and can decrease the extension rate of cirrhotic PVT
(OR 0.33, 95% CI 0.18-0.62, I2 = 41.0%), without increasing the
incidence of total bleeding (OR 1.21, 95% CI 0.75-1.97,
I2 = 9.8%), major bleeding (OR 0.98, 95% CI 0.49-1.95,
I2 = 19.7%), and variceal bleeding (OR 0.35, 95% CI
0.12-1.01, I2 = 39.9%). Subgroup analysis showed that VKA, LMWH,
and DOACs could increase the recanalization rate of PVT and were not
associated with the risk of bleeding. Studies that compared direct oral
anticoagulants (DOACs) with warfarin directly showed that the recanalization
rate of PVT in the DOACs group might be higher than that in the warfarin
group (OR 30.99, 95% CI 7.39-129.87, I2 = 0.0%), and there was no
difference in the rate of total bleeding (OR 0.30, 95% CI 0.01-8.65,
I2 = 79.6%). Conclusions Anticoagulants are safe and effective in patients with cirrhotic PVT. The
rate of PVT recanalization associated with DOACs may be higher than
warfarin.
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Affiliation(s)
- Zhiqi Zhang
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,College of Pharmacy, 26455Capital Medical University, Beijing, China
| | - Ying Zhao
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Baofeng Han
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,College of Pharmacy, 26455Capital Medical University, Beijing, China
| | - Zhijun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Liying Sun
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiangli Cui
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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9
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Wang HL, Lu WJ, Zhang YL, Nie CH, Zhou TY, Zhou GH, Zhu TY, Wang BQ, Chen SQ, Yu ZN, Jing L, Sun JH. Comparison of Transjugular Intrahepatic Portosystemic Shunt in the Treatment of Cirrhosis With or Without Portal Vein Thrombosis: A Retrospective Study. Front Med (Lausanne) 2021; 8:737984. [PMID: 34671621 PMCID: PMC8523019 DOI: 10.3389/fmed.2021.737984] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/06/2021] [Indexed: 12/27/2022] Open
Abstract
Aim: The purpose of our study was to conduct a retrospective analysis to compare the effectiveness of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of patients with cirrhosis with or without portal vein thrombosis (PVT). Methods: We included a total of 203 cirrhosis patients successfully treated with TIPS between January 2015 and January 2018, including 72 cirrhosis patients with PVT (35.5%) and 131 without PVT (64.5%). Our subjects were followed for at least 1 year after treatment with TIPS. Data were collected to estimate the mortality, shunt dysfunction, and complication rates after TIPS creation. Results: During the mean follow-up time of 19.5 ± 12.8 months, 21 (10.3%) patients died, 15 (7.4%) developed shunt dysfunction, and 44 (21.6%) experienced overt hepatic encephalopathy (OHE). No significant differences in mortality (P = 0.134), shunt dysfunction (P = 0.214), or OHE (P = 0.632) were noted between the groups. Age, model for end-stage liver disease (MELD) score, and refractory ascites requiring TIPS were risk factors for mortality. A history of diabetes, percutaneous transhepatic variceal embolization (PTVE), 8-mm diameter stent, and platelet (PLT) increased the risk of shunt dysfunction. The prevalence of variceal bleeding and recurrent ascites was comparable between the two groups (16.7 vs. 16.7% P = 0.998 and 2.7 vs. 3.8% P = 0.678, respectively). Conclusions: Transjugular intrahepatic portosystemic shunts are feasible in the management of cirrhosis with PVT. No significant differences in survival or shunt dysfunction were noted between the PVT and no-PVT groups. The risk of recurrent variceal bleeding, recurrent ascites, and OHE in the PVT group was generally similar to that in the no-PVT group. TIPS represents a potentially feasible treatment option in cirrhosis patients with PVT.
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Affiliation(s)
- Hong-Liang Wang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Wei-Jie Lu
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yue-Lin Zhang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Chun-Hui Nie
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Tan-Yang Zhou
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Guan-Hui Zhou
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Tong-Yin Zhu
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Bao-Quan Wang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Sheng-Qun Chen
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Zi-Niu Yu
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Li Jing
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China
| | - Jun-Hui Sun
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, China.,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
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10
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Xu S, Guo X, Yang B, Romeiro FG, Primignani M, Méndez-Sánchez N, Yoshida EM, Mancuso A, Tacke F, Noronha Ferreira C, De Stefano V, Qi X. Evolution of Nonmalignant Portal Vein Thrombosis in Liver Cirrhosis: A Pictorial Review. Clin Transl Gastroenterol 2021; 12:e00409. [PMID: 34597281 PMCID: PMC8483868 DOI: 10.14309/ctg.0000000000000409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/22/2021] [Indexed: 02/07/2023] Open
Abstract
Portal vein thrombosis (PVT) is a common complication in liver cirrhosis, especially in advanced cirrhosis. It may be related to a higher risk of liver-related events and liver function deterioration. Imaging examinations can not only provide an accurate diagnosis of PVT, such as the extent of thrombus involvement and the degree of lumen occupied, but also identify the nature of thrombus (i.e., benign/malignant and acute/chronic). Evolution of PVT, mainly including development, recanalization, progression, stability, and recurrence, could also be assessed based on the imaging examinations. This article briefly reviews the pathophysiology, diagnosis, classification, and evolution of PVT with an emphasis on their computed tomography imaging features.
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Affiliation(s)
- Shixue Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China
- Graduate School, China Medical University, Shenyang, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Benqiang Yang
- Department of Radiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Fernando Gomes Romeiro
- Department of Internal Medicine, Botucatu Medical School, UNESP-Univ Estadual Paulista. Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, Brazil
| | - Massimo Primignani
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic and Foundation and Faculty of Medicine. National Autonomous University of Mexico, Mexico City, Mexico
| | - Eric M. Yoshida
- Division of Gastroenterology, University of British Columbia and Vancouver General Hospital, Vancouver, Canada
| | - Andrea Mancuso
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico, Di Cristina-Benfratelli, Palermo, Italy
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Valerio De Stefano
- Dipartimento Di Diagnostica Per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China
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11
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Dong S, Qi H, Li Y, Men P, Alifu M, Zhang Y, Li Y, Zhao R. A systematic review and meta-analysis of anticoagulation therapy for portal vein thrombosis in patients with cirrhosis: to treat or not to treat? Hepatol Int 2021; 15:1356-1375. [PMID: 34487316 DOI: 10.1007/s12072-021-10233-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 07/01/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE To date, the optimal treatment for portal vein thrombosis (PVT) in cirrhotic patients has not been established in guidelines or consensus. We conducted a systematic review and meta-analysis to evaluate the effect of anticoagulation therapy in patients with cirrhosis and PVT. METHODS PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched (until 31st October 2020) for studies evaluating the effect of anticoagulation therapy on treating PVT in patients with cirrhosis. Odds ratios (ORs) and their 95% confidence intervals (CIs) were pooled using the Mantel-Haenszel method. RESULTS A total of 13 studies were included in the analysis, comprising 6005 patients. Of these, three were prospective cohort studies, nine were retrospective cohort studies and one was case-control study. Compared to no treatment, anticoagulation therapy was associated with higher rates of PVT recanalization (OR 4.29; 95% CI 3.01-6.13). Anticoagulation therapy demonstrated a significant 74% reduction in PVT extension compared to no treatment (OR 0.26; 95% CI 0.14-0.49). Anticoagulation therapy was associated with a nonsignificantly lower risk of death (OR 0.53; 95% CI 0.20-1.40). However, anticoagulation therapy was associated with slightly higher risk of bleeding compared to no treatment (OR 1.16; 95% CI 1.02-1.32). CONCLUSIONS In cirrhotic patients with PVT, anticoagulation therapy helps increase rate of PVT recanalization and improve survival, but may also carry higher risks of bleeding compared to no treatment. Our findings support the use of anticoagulation in cirrhotic patients with PVT.
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Affiliation(s)
- Shujie Dong
- Department of Pharmacy, Peking University Third Hospital, No.49 Huayuan North Road, Beijing, 100191, China
| | - Huihong Qi
- Department of Pharmacy, Tangshan Gongren Hospital, Tangshan, Hebei, China
| | - Yan Li
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Peng Men
- Department of Pharmacy, Peking University Third Hospital, No.49 Huayuan North Road, Beijing, 100191, China
| | - Maiwujudan Alifu
- Department of Pharmacy, The Sixth Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Yatong Zhang
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yongjun Li
- Department of Vascular Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1 Dahua Road, Beijing, 100730, China.
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, No.49 Huayuan North Road, Beijing, 100191, China.
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12
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Safety and Efficacy of Anticoagulation in Patients with Cirrhosis: A Meta-Analysis. Can J Gastroenterol Hepatol 2021; 2021:8859602. [PMID: 34007837 PMCID: PMC8102101 DOI: 10.1155/2021/8859602] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 01/06/2021] [Accepted: 02/08/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND AIMS Portal vein thrombosis is a serious adverse event that occurs during liver cirrhosis. We performed a meta-analysis to evaluate the safety and efficacy of anticoagulant therapy and prophylactic anticoagulant therapy in cirrhosis patients with (/without) portal vein thrombosis. METHODS Eligible comparative studies were identified by searching the following electronic databases: PubMed, Embase, Cochrane Library, Web of Science, and CNKI. A meta-analysis was performed to calculate odds ratios and 95% confidence intervals using fixed-effects models. Recanalization and thrombus progression were defined as the primary outcomes. Secondary outcomes included adverse events and death mortality. RESULTS A total of 3479 patients were included in this analysis. Compared with the control group, the recanalization rate in the anticoagulant therapy group was increased (P < 0.00001) in patients with cirrhosis and portal vein thrombosis without increasing adverse events. Multiple use of enoxaparin in small doses is safer than single large doses (P=0.004). Direct oral anticoagulants are more effective (P < 0.00001) and safer than traditional anticoagulants. Prophylactic anticoagulant therapy can effectively prevent portal vein thrombosis formation (P < 0.00001). CONCLUSIONS Anticoagulation therapy can treat or prevent portal vein thrombosis in patients with liver cirrhosis and is a relatively safe treatment.
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13
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Wu Y, Li H, Zhang T, Bai Z, Xu X, Levi Sandri GB, Wang L, Qi X. Splanchnic Vein Thrombosis in Liver Cirrhosis After Splenectomy or Splenic Artery Embolization: A Systematic Review and Meta-Analysis. Adv Ther 2021; 38:1904-1930. [PMID: 33687650 DOI: 10.1007/s12325-021-01652-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/03/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Splenectomy and splenic artery embolization are major treatment options for hypersplenism and portal hypertension in liver cirrhosis, but may lead to splanchnic vein thrombosis (SVT), which is potentially lethal. We conducted a systematic review and meta-analysis to explore the incidence of SVT in liver cirrhosis after splenectomy or splenic artery embolization and the risk factors for SVT. METHODS All relevant studies were searched through the PubMed, EMBASE, and Cochrane Library databases. The incidence of SVT in liver cirrhosis after splenectomy or splenic artery embolization was pooled. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS Sixty-six studies with 5632 patients with cirrhosis were included. The pooled incidence of SVT after splenectomy and splenic artery embolization was 24.6% (95% CI 20.2-29.3%) and 11.7% (95% CI 7.1-17.3%), respectively. A meta-analysis of three comparative studies demonstrated that the incidence of SVT after splenectomy was statistically similar to that after splenic artery embolization (OR 3.15, P = 0.290). Platelet count, mean platelet volume, preoperative splenic or portal vein diameter, preoperative or postoperative portal blood velocity, splenic volume and weight, and periesophagogastric devascularization were significant risk factors for SVT after splenectomy. Postoperative use of preventive antithrombotic therapy was a significant protective factor against SVT after splenectomy. CONCLUSIONS SVT is common in liver cirrhosis after splenectomy and splenic artery embolization. Coagulation and hemostasis factors, anatomical factors, and surgery-related factors have been widely identified for the assessment of high risk of SVT after splenectomy. Prophylactic strategy after splenectomy, such as antithrombotic therapy, might be considered in such high-risk patients. STUDY REGISTRATION This study was registered in PROSPERO with a registration number of CRD42019129673.
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Affiliation(s)
- Yanyan Wu
- 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, People's Republic of China
- Postgraduate College, Jinzhou Medical University, Jinzhou, People's Republic of China
| | - Hongyu Li
- 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, People's Republic of China
| | - Tiansong Zhang
- Department of Traditional Chinese Medicine, Jing'an District Central Hospital, Shanghai, China
| | - 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, People's Republic of China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, People's Republic of China
| | - 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, People's Republic of China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, People's Republic of China
| | | | - Le Wang
- 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, People's Republic of China
- Postgraduate College, Dalian Medical University, Dalian, People's Republic of 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, People's Republic of China.
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14
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Consensus for management of portal vein thrombosis in liver cirrhosis (2020, Shanghai). J Dig Dis 2021; 22:176-186. [PMID: 33470535 PMCID: PMC8252415 DOI: 10.1111/1751-2980.12970] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/10/2021] [Accepted: 01/17/2021] [Indexed: 12/11/2022]
Abstract
Portal vein thrombosis (PVT) is a common and severe complication of liver cirrhosis. So far, there have been few consensuses or practice guidelines on the management of PVT in liver cirrhosis. In this expert consensus, we systematically review the epidemiology, risk factors, imaging examinations, diagnosis, assessment of disease severity, and treatment strategy of PVT in liver cirrhosis, based on the most recent evidence and expert opinions, to further standardize the diagnosis and treatment of the disease in clinical practice.
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15
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Anticoagulant Treatment for Splanchnic Vein Thrombosis in Liver Cirrhosis: A Systematic Review and Meta-Analysis. Thromb Haemost 2021; 121:867-876. [PMID: 33525037 DOI: 10.1055/s-0040-1722192] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Splanchnic vein thrombosis (SVT) is a common complication in patients with liver cirrhosis. The aim of this study was to evaluate the efficacy and safety of anticoagulant therapy for SVT in cirrhotic patients. METHODS In this systematic review and meta-analysis, studies reporting on SVT recanalization and progression, recurrent venous thromboembolism (VTE), major bleeding, and overall mortality were searched in MEDLINE, EMBASE, and ClinicalTrial.gov up to December 2019. Pooled proportions and risk ratios (RRs) with corresponding 95% confidence intervals (CIs) were calculated. RESULTS A total of 1,475 patients were included in 26 studies (23 observational and 3 randomized controlled trials). In patients receiving anticoagulant therapy, SVT recanalization occurred in 68% (95% CI, 62-74; 571/842 patients; 22 studies), SVT progression in 6% (95% CI, 4-9; 25/748 patients; 22 studies), recurrent VTE in 10% (95% CI, 4-22; 48/399 patients; 7 studies), major bleeding in 6% (95% CI, 4-10; 58/785 patients; 18 studies), and overall mortality in 9% (95% CI, 6-14; 68/787 patients; 17 studies). Anticoagulant treatment was associated with higher SVT recanalization (RR 3.19; 95% CI, 1.42-7.17), lower thrombosis progression (RR 0.28; 95% CI, 0.15-0.52), major bleeding (RR 0.52; 95% CI, 0.28-0.97), and overall mortality (RR 0.42; 95% CI, 0.24-0.73) compared with no treatment. CONCLUSION Anticoagulant therapy seems to improve vein recanalization and to reduce SVT progression, major bleeding, and overall mortality in cirrhotic patients with SVT. The incidence of recurrent VTE during anticoagulation remains substantial.
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16
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Ogawa S, Yamamoto A, Jogo A, Nakano MM, Kageyama K, Sohgawa E, Nishida N, Kaminou T, Miki Y. Splenic Vein Diameter is a Risk Factor for the Portal Venous System Thrombosis After Partial Splenic Artery Embolization. Cardiovasc Intervent Radiol 2021; 44:921-930. [PMID: 33474605 PMCID: PMC8172394 DOI: 10.1007/s00270-020-02751-8] [Citation(s) in RCA: 11] [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: 06/15/2020] [Accepted: 12/16/2020] [Indexed: 01/16/2023]
Abstract
Purpose Portal venous system thrombosis is a complication of partial splenic artery embolization, and pre-treatment risk assessment is thus important. The purpose of this study was to identify the risk factors for portal venous system thrombosis after partial splenic artery embolization. Materials and methods We retrospectively analyzed 67 consecutive patients who underwent contrast-enhanced computed tomography before and after first partial splenic artery embolization between July 2007 and October 2018. As risk factors, we investigated age, sex, hematological data, liver function, steroid use, heparin use, and findings from pre- and post-treatment computed tomography. Uni- and multivariate analyses were performed to evaluate the relationship between thrombus appearance or growth and these factors. Values of p < 0.05 were considered significant. Results Partial splenic artery embolization was technically successful in all 67 patients. Nine patients showed appearance or growth of thrombus. Univariate analysis showed maximum diameter of the splenic vein before treatment (p = 0.0076), percentage of infarcted spleen (p = 0.017), and volume of infarcted spleen (p = 0.022) as significant risk factors. Multivariate analysis showed significant differences in maximum diameter of the splenic vein before treatment (p = 0.041) and percentage of infarcted spleen (p = 0.023). According to receiver operating characteristic analysis, cutoffs for maximum diameter of the splenic vein and percentage of infarcted spleen for distinguishing the appearance or growth of thrombus were 17 mm and 58.2%. Conclusion Large maximum diameter of the splenic vein before partial splenic artery embolization and high percentage of infarcted spleen after partial splenic artery embolization were identified as risk factors for portal venous system thrombosis. Level of Evidence Level 4, Case Series
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Affiliation(s)
- Satoyuki Ogawa
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan.
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Mariko M Nakano
- Department of Radiology, National Hospital Organization Osaka Minami Medical Center, Osaka, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Norifumi Nishida
- Department of Diagnostic Radiology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Toshio Kaminou
- Department of Radiology, Tsukazaki Hospital, Himeji, Hyogo, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
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17
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Wang L, Guo X, Xu X, De Stefano V, Plessier A, Noronha Ferreira C, Qi X. Anticoagulation Favors Thrombus Recanalization and Survival in Patients With Liver Cirrhosis and Portal Vein Thrombosis: Results of a Meta-Analysis. Adv Ther 2021; 38:495-520. [PMID: 33155180 PMCID: PMC7854392 DOI: 10.1007/s12325-020-01550-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/23/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Benefit and risk of anticoagulation in cirrhotic patients with portal vein thrombosis (PVT) remain controversial, especially in those with asymptomatic PVT and in non-liver transplant candidates. Furthermore, the predictors of portal vein recanalization and bleeding events after anticoagulation are critical for making clinical decisions, but still unclear. We conducted a meta-analysis to investigate the outcomes of anticoagulation for PVT in liver cirrhosis and explore the predictors of portal vein recanalization and bleeding events after anticoagulation. METHODS All studies regarding anticoagulation for PVT in liver cirrhosis were searched via PubMed, EMBASE, and Cochrane Library databases. Thrombotic outcomes, bleeding events, and survival were compared between anticoagulation and non-anticoagulation groups. Predictors of portal vein recanalization and bleeding events were pooled. Risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs) were calculated. RESULTS Thirty-three studies including 1696 cirrhotic patients with PVT were included. Anticoagulation significantly increased portal vein recanalization (RR = 2.61; 95% CI 1.99-3.43; P < 0.00001) and overall survival (RR = 1.11; 95% CI 1.03-1.21; P = 0.01) and decreased thrombus progression (RR = 0.26; 95% CI 0.14-0.49; P < 0.0001). Anticoagulation did not significantly influence overall bleeding (RR = 0.78; 95% CI 0.47-1.30; P = 0.34). Early initiation of anticoagulation (RR = 1.58; 95% CI 1.21-2.07; P = 0.0007) significantly increased portal vein recanalization. Child-Pugh class B and C (RR = 0.77; 95% CI 0.62-0.95; P = 0.02) and higher MELD score (MD = - 1.48; 95% CI - 2.20-0.76; P < 0.0001) were significantly associated with decreased portal vein recanalization. No predictor significantly associated with bleeding events was identified. CONCLUSIONS Early initiation of anticoagulation should be supported in liver cirrhosis with PVT. Predictors of portal vein recanalization should be taken into consideration to identify those who may not benefit from anticoagulation. REGISTRATION The work was registered in PROSPERO with registration no. CRD42020157142.
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Affiliation(s)
- Le Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Dalian Medical University, Dalian, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), Shenyang, China
| | - Xiangbo Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), Shenyang, China
| | - Valerio De Stefano
- Dipartimento Di Diagnostica Per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Aurelie Plessier
- Hôpital Beaujon, AP-HP, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Centre de Référence Des Maladies Vasculaires du Foie, Inserm U1149, Centre de Recherche Sur L'Inflammation (CRI), Université Paris 7-Denis-Diderot, ERN Rare Liver Clichy, Paris, France
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia E Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), Shenyang, China.
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18
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Sato K, Sakamoto Y, Sakai M, Ishikawa C, Nakazawa M, Cheng CJ, Watari T, Nakayama T. Diagnostic utility of computed tomographic angiography in dogs with portal vein thrombosis. J Vet Med Sci 2020; 82:1421-1427. [PMID: 32814748 PMCID: PMC7653315 DOI: 10.1292/jvms.20-0226] [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] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Computed tomographic (CT) angiography, the gold standard for diagnosing portal vein
thrombosis (PVT) in humans, is poorly documented in dogs. Therefore, we retrospectively
reviewed dogs with PVT diagnosed by CT angiography. Medical records of 13 client-owned
dogs diagnosed with PVT by CT angiography were reviewed. All dogs had chronic PVT, and the
most frequent clinical sign was vomiting (5/13), with pancreatitis the most frequent
concurrent disease (6/13). All dogs tested for plasma D-dimer concentration (12/12)
revealed elevated levels. On CT angiography, a thrombus was detected as a non-contrast
enhancement structure in the portal vessel of 13 dogs. There was no evidence of complete
obstruction of the portal vein in any of the dogs. The median luminal filling of the
portal vein was 60.4%. The thrombus extension was variable among dogs, with a median of
34.9 mm. CT angiography identified the thrombus in the main portal vein of 12/13 dogs and
multiple thrombus formation other than the main portal vein in 9/13 dogs. CT angiography
provided specific information such as detecting the presence, location, and number of PVT
in dogs. Therefore, CT angiography might be useful for the diagnosis and follow-up
evaluation of PVT in dogs.
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Affiliation(s)
- Keita Sato
- Department of Veterinary Medicine, College of Bioresource Sciences, Nihon University, 1866 Kameino, Fujisawa, Kanagawa 252-0880, Japan
| | - Yumi Sakamoto
- Department of Veterinary Medicine, College of Bioresource Sciences, Nihon University, 1866 Kameino, Fujisawa, Kanagawa 252-0880, Japan
| | - Manabu Sakai
- Department of Veterinary Medicine, College of Bioresource Sciences, Nihon University, 1866 Kameino, Fujisawa, Kanagawa 252-0880, Japan
| | - Chieko Ishikawa
- Department of Veterinary Medicine, College of Bioresource Sciences, Nihon University, 1866 Kameino, Fujisawa, Kanagawa 252-0880, Japan
| | - Megu Nakazawa
- Department of Veterinary Medicine, College of Bioresource Sciences, Nihon University, 1866 Kameino, Fujisawa, Kanagawa 252-0880, Japan
| | - Chieh-Jen Cheng
- Department of Veterinary Medicine, College of Bioresource Sciences, Nihon University, 1866 Kameino, Fujisawa, Kanagawa 252-0880, Japan
| | - Toshihiro Watari
- Department of Veterinary Medicine, College of Bioresource Sciences, Nihon University, 1866 Kameino, Fujisawa, Kanagawa 252-0880, Japan
| | - Tomohiro Nakayama
- Department of Veterinary Medicine, College of Bioresource Sciences, Nihon University, 1866 Kameino, Fujisawa, Kanagawa 252-0880, Japan
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19
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Zhang L, Huan H, Tong H, Wei B, Wang Z, Liu C, Wu H. Warfarin prevented de novo portal vein thrombosis after transjugular intrahepatic portosystemic shunt: A retrospective study. Medicine (Baltimore) 2020; 99:e18737. [PMID: 31914090 PMCID: PMC6959952 DOI: 10.1097/md.0000000000018737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Portal vein thrombosis (PVT) might impair the prognosis of cirrhotic patients. However, formation of de novo PVT after transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients without preexisting PVT was rarely reported. Moreover, it is not known whether warfarin is efficient in preventing de novo PVT after TIPS. The current study aimed to investigate retrospectively the incidence and location of de novo PVT, and preventive effects of warfarin on de novo PVT after TIPS for cirrhotic patients. Patients who received TIPS placement between March 1, 2015 and March 1, 2016 in our hospital were screened retrospectively. Patients without preexisting PVT before TIPS and those who were followed up for at least 12 months were included. There were 2 groups: 1 group received warfarin (warfarin group) post-TIPS, while another group (control group) did not receive prophylactic drug to prevent PVT. Their baseline characteristics and follow-up data were retrieved. The occurrence of PVT, adverse events due to warfarin, difference in stent patency and clinical complications such as stent dysfunction, hepatic encephalopathy, mortality, liver cancer, variceal bleeding, infection, and liver failure, and results of follow-up biochemical examination were compared. Eighty-three patients without preexisting PVT were included. There were 56 patients in the control group and 27 in the warfarin group. The incidence of PVT in the warfarin group was 14.8% (4/27), whereas the incidence in the control group was 42.9% (24/56, P = .013). The location of de novo PVT was mainly at left portal vein. Adverse events due to warfarin was mostly mild, such as hemorrhinia and gingival hemorrhage. No significant difference regarding to stent patency and clinical complications between the 2 groups was found. At 24-month after-TIPS, for the remaining patients in both groups, the total bilirubin was significantly increased while the red blood cell count was significantly decreased in control group compared with those in warfarin group (P < .05). PVT could commonly occur after TIPS in patients without preexisting PVT. Warfarin could prevent PVT in these patients, and might improve patient's liver function.
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Affiliation(s)
- Linhao Zhang
- Department of Gastroenterology
- Laboratory of Gastroenterology and Hepatology, West China Hospital, Sichuan University
| | - Hui Huan
- Department of Gastroenterology
- Department of Gastroenterology, Hospital of Chengdu Office of People's Government of Tibetan autonomous Region, Sichuan, China
| | | | - Bo Wei
- Department of Gastroenterology
| | | | - Chao Liu
- Department of Gastroenterology, Hospital of Chengdu Office of People's Government of Tibetan autonomous Region, Sichuan, China
| | - Hao Wu
- Department of Gastroenterology
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Intagliata NM, Caldwell SH, Tripodi A. Diagnosis, Development, and Treatment of Portal Vein Thrombosis in Patients With and Without Cirrhosis. Gastroenterology 2019; 156:1582-1599.e1. [PMID: 30771355 DOI: 10.1053/j.gastro.2019.01.265] [Citation(s) in RCA: 188] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 01/11/2019] [Accepted: 01/21/2019] [Indexed: 02/06/2023]
Abstract
Portal vein thrombosis unrelated to solid malignancy is common in patients with cirrhosis, but less frequently observed in patients without cirrhosis. Prompt diagnosis and management of acute symptomatic portal vein thrombosis are essential. Failure to detect and treat thromboses can result in mesenteric ischemia, chronic cavernous transformation, and complications of portal hypertension. In patients with cirrhosis, development of portal vein thrombosis is often insidious and remains undetected until its incidental detection. Management of portal vein thrombosis in patients with cirrhosis is more controversial. However, there are data to support treatment of specific patients with anticoagulation agents. We review the common and distinct features of portal vein thromboses in patients without liver tumors, with and without cirrhosis.
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Affiliation(s)
- Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, University of Virginia Medical CenterCharlottesville, Virginia.
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia Medical CenterCharlottesville, Virginia
| | - Armando Tripodi
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
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21
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Comparison of TIPS alone and combined with partial splenic embolization (PSE) for the management of variceal bleeding. Eur Radiol 2019; 29:5032-5041. [PMID: 30796573 DOI: 10.1007/s00330-019-06046-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/31/2018] [Accepted: 01/24/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Transjugular intrahepatic portosystemic shunt (TIPS) and partial splenic embolization (PSE) were two interventional radiological treatments for the complications of cirrhosis. This study aimed to investigate the effects of concomitant PSE on the long-term shunt patency and overall survival of TIPS-treated patients. METHODS Forty-eight patients with TIPS insertion were enrolled and studied retrospectively. They were divided into TIPS+PSE (n = 16) and TIPS groups (n = 32), undergoing combined therapy using TIPS and PSE, and monotherapy using TIPS alone, respectively. RESULTS The 5-year cumulative primary patency rate in the TIPS+PSE group was markedly higher than in the TIPS group (56.8% vs. 32.8%, p = 0.028), whereas the 5-year cumulative secondary patency rate (93.8% vs. 87.7%, p = 0.749) and overall survival rate (62.5% vs. 30.7%, p = 0.414) were not significantly different between the two groups. Cox-regression models revealed that group (hazard ratio [HR], 0.235; 95% CI, 0.084-0.665; p = 0.006), portal venous pressure decline (HR, 0.687; 95% CI, 0.563-0.838; p = 0.000), and baseline portal vein thrombosis (HR, 3.955; 95% CI, 1.634-9.573; p = 0.002) were significant predictors for shunt dysfunction, while only ascites (HR, 2.941; 95% CI, 1.250-6.920; p = 0.013) was a significant predictor for mortality. No severe adverse event was noted in the two groups except for the potential risk of splenic abscess development in the TIPS+PSE group. CONCLUSIONS Concomitant PSE may help increase the long-term primary shunt patency rate, but not the overall survival of TIPS-treated patients. Further prospective studies are needed to validate these retrospective findings and to investigate the potential mechanisms. KEY POINTS • Combined therapy using TIPS and PSE is associated with higher primary patency rates than TIPS alone. • Combined therapy using TIPS and PSE is associated with similar rates of secondary patency and overall survival of patients than TIPS alone. • Group (TIPS alone or TIPS+PSE), PVD, and baseline PVT are three independent predictors for shunt dysfunction, while ascites is the only independent predictor for mortality.
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22
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Qi X, Guo X, Yoshida EM, Méndez-Sánchez N, De Stefano V, Tacke F, Mancuso A, Sugawara Y, Yang SS, Teschke R, Arora A, Valla DC. Transient portal vein thrombosis in liver cirrhosis. BMC Med 2018; 16:83. [PMID: 29871683 PMCID: PMC5989335 DOI: 10.1186/s12916-018-1069-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/07/2018] [Indexed: 02/07/2023] Open
Abstract
In real-world clinical practice, the acceptance of anticoagulation therapy in the management of portal vein thrombosis (PVT) in patients with cirrhosis is limited by the fear of an increased bleeding risk. Additionally, accumulating evidence indicates that spontaneous recanalization of PVT may occur in the absence of antithrombotic treatment. Therefore, risk stratification based on outcomes in such patients is crucial for determining a therapeutic strategy. In this paper, we draw attention to the distinct clinical entity, "transient PVT" by introducing two cases with PVT that spontaneously recanalized in the absence of antithrombotic treatment. We reviewed the available data regarding the probability of and predictors for spontaneous recanalization of PVT. Available data suggest singling out transient thrombosis in the natural history of PVT in patients with cirrhosis because of its prognostic and management implications.
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Affiliation(s)
- Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, 110840 Liaoning Province China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, 110840 Liaoning Province China
| | - Eric M. Yoshida
- 0000 0001 0684 7796grid.412541.7Division of Gastroenterology, Vancouver General Hospital, Vancouver, BC Canada
| | - Nahum Méndez-Sánchez
- grid.414741.3Liver Research Unit Medica Sur Clinic & Foundation, Mexico City, Mexico
| | - Valerio De Stefano
- 0000 0001 0941 3192grid.8142.fInstitute of Hematology, Catholic University, Rome, Italy
| | - Frank Tacke
- 0000 0001 0728 696Xgrid.1957.aDepartment of Medicine III, RWTH Aachen University, Aachen, Germany
| | - Andrea Mancuso
- grid.419995.9Department of Internal Medicine, ARNAS Civico, Palermo, Italy
- grid.416200.1Hepatology and Gastroenterology, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Yasuhiko Sugawara
- 0000 0001 0660 6749grid.274841.cDepartment of Transplantation and Pediatric Surgery, Postgraduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Sien-Sing Yang
- 0000 0004 0627 9786grid.413535.5Liver Unit, Cathay General Hospital and Fu-Jen Catholic University School of Medicine, Taipei, Taiwan
| | - Rolf Teschke
- 0000 0004 0558 9854grid.470005.6Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, D-63450 Hanau, Germany
| | - Ankur Arora
- 0000 0004 0581 2008grid.451052.7Department of Radiology, Worthing Hospital, Western Sussex NHS Foundation Trust, West Sussex, UK
| | - Dominique-Charles Valla
- 0000 0001 2175 4109grid.50550.35Service d’hépatologie, Hôpital Beaujon, APHP, Clichy-la-Garenne, Paris, France
- 0000 0001 2217 0017grid.7452.4Université Paris-Diderot and Inserm, Paris, France
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Qi X, Valla DC, Guo X. Anticoagulation for Portal Vein Thrombosis in Cirrhosis: Selection of Appropriate Patients. Gastroenterology 2018; 154:760-761. [PMID: 29351830 DOI: 10.1053/j.gastro.2017.09.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 09/01/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
| | - Dominique-Charles Valla
- Service d'hépatologie, Hôpital Beaujon, APHP, Clichy-la-Garenne and Université Paris-Diderot and Inserm, Paris, France
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
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24
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Loffredo L, Pastori D, Farcomeni A, Violi F. Effects of Anticoagulants in Patients With Cirrhosis and Portal Vein Thrombosis: A Systematic Review and Meta-analysis. Gastroenterology 2017; 153:480-487.e1. [PMID: 28479379 DOI: 10.1053/j.gastro.2017.04.042] [Citation(s) in RCA: 251] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/13/2017] [Accepted: 04/26/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Liver cirrhosis is complicated by bleeding from portal hypertension but also by portal vein thrombosis (PVT). PVT occurs in approximately 20% to 50% of patients with cirrhosis, and is a warning sign for poor outcome. It is a challenge to treat patients with cirrhosis using anticoagulants, because of the perception that the coexistent coagulopathy could promote bleeding. We performed a systematic review and meta-analysis to determine the effects of anticoagulant therapy in patients with cirrhosis and PVT. METHODS We searched the PubMed, ISI Web of Science, SCOPUS, and Cochrane databases through February 14, 2017, for studies that assessed the effect of anticoagulant therapy vs no treatment in patients with cirrhosis and PVT. We performed a meta-analysis to estimate the effect of anticoagulant treatment vs no therapy on recanalization and progression of PVT in patients with cirrhosis. We also assessed variceal and nonvariceal bleeding. RESULTS We analyzed data from 8 studies, comprising 353 patients, that assessed the effects of anticoagulant therapy (low-weight heparin or warfarin vs no therapy) in patients with cirrhosis and PVT; these studies reported rates of complete and partial recanalization. A significantly higher proportion of patients treated with anticoagulants underwent PVT recanalization than patients who did not receive anticoagulants (71% vs 42%, respectively; P < .0001). From 6 studies (comprising 217 patients), 53% of patients treated with anticoagulants vs 33% of patients who did not receive anticoagulants had complete PVT recanalization (P = .002). From 6 studies (comprising 225 patients), PVT progressed in 9% of patients treated with anticoagulants vs 33% of patients who did not receive these drugs (P < .0001). Six studies (257 patients) reported rates of any bleeding; there was no difference in the proportions of patients with major or minor bleeding between groups that did vs did not receive anticoagulants (11% for both groups). Four studies (comprising 158 patients) reported rates of spontaneous variceal bleeding, which occurred in a significantly lower proportion of patients who received anticoagulants vs those who did not (P = .04). CONCLUSIONS Based on a systematic review and meta-analysis, patients with cirrhosis and PVT who receive anticoagulant therapy have increased recanalization and reduced progression of thrombosis, compared with patients who do not receive anticoagulants, with no excess of major and minor bleedings and less incidence of variceal bleeding.
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Affiliation(s)
- Lorenzo Loffredo
- Department of Internal Medicine and Medical Specialties, Sapienza University, Rome, Italy
| | - Daniele Pastori
- Department of Internal Medicine and Medical Specialties, Sapienza University, Rome, Italy; Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Rome, Italy
| | - Alessio Farcomeni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Roma, Italy
| | - Francesco Violi
- Department of Internal Medicine and Medical Specialties, Sapienza University, Rome, Italy.
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25
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Zhang JY, Wang YB, Gong JP, Zhang F, Zhao Y. Postoperative Anticoagulants in Preventing Portal Vein Thrombosis in Patients Undergoing Splenectomy Because of Liver Cirrhosis: A Meta-Analysis. Am Surg 2016. [DOI: 10.1177/000313481608201222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Portal vein thrombosis (PVT) frequently occurs in patients undergoing splenectomy because of liver cirrhosis. Whether the use of postoperative anticoagulants can decrease the incidence of PVT in these subjects is inconclusive. Moreover, the safety of the use of postoperative anticoagulants in the aforementioned patients is a concern. This meta-analysis aims to explore the effectiveness and safety of the preventive anticoagulants to prevent PVT in patients undergoing splenectomy because of liver cirrhosis. Four English language databases (i.e., PubMed, Embase, Cochrane Library, and Web of Science) and four Chinese language databases (i.e., Wanfang, CNKI, Cqvip, and CBM) were searched for randomized controlled trials, cohort studies, and case-control studies on the use of preventive anticoagulants to prevent PVT in patients undergoing splenectomy because of liver cirrhosis from their inception to September 15, 2015. The primary outcome was postoperative PVT incidence. The secondary outcomes included postoperative complications and adverse reaction. Study-specific odds ratios were combined to calculate pooled value through a fixed effects model. A total of 17 original studies were included, involving 1,497 patients. This meta-analysis showed that the preventive anticoagulant group had a lower incidence of PVT than the no anticoagulant group (odds ratio, 0.31; 95% confidence interval, 0.23–0.40; P < 0.05). According to the description of limited studies, the upper gastrointestinal hemorrhage mainly occurred in the no anticoagulant group. Meanwhile, the adverse reaction was trivial in the group using anticoagulants, which could easily be released with no special management. Postoperative anticoagulants can effectively decrease PVT incidence in subjects undergoing splenectomy because of liver cirrhosis. These published studies are more prone to show that no serious negative influence of anticoagulants exists in the aspect of safety. However, further studies are still needed.
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Affiliation(s)
- Jian-Ying Zhang
- Graduate School, Chongqing Medical University
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University
| | - Yun-Bing Wang
- Graduate School, Chongqing Medical University
- Department of Hepatobiliary, The Second Affiliated Hospital of Chongqing Medical University; and
| | - Jian-Ping Gong
- Department of Hepatobiliary, The Second Affiliated Hospital of Chongqing Medical University; and
| | - Fan Zhang
- School of Public Health and Management, Chongqing Medical University, Chongqing, China
| | - Yong Zhao
- School of Public Health and Management, Chongqing Medical University, Chongqing, China
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26
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Luz JHM, Luz PM, Marchiori E, Rodrigues LA, Gouveia HR, Martin HS, Faria IM, Souza RR, Gil RDA, Palladino ADM, Pimenta KB, de Souza HS. Partial splenic embolization to permit continuation of systemic chemotherapy. Cancer Med 2016; 5:2715-2720. [PMID: 27611010 PMCID: PMC5083724 DOI: 10.1002/cam4.856] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/08/2016] [Accepted: 07/16/2016] [Indexed: 12/16/2022] Open
Abstract
Systemic chemotherapy treatments, commonly those that comprise oxaliplatin, have been linked to the appearance of distinctive liver lesions that evolves to portal hypertension, spleen enlargement, platelets sequestration, and thrombocytopenia. This outcome can interrupt treatment or force dosage reduction, decreasing efficiency of cancer therapy. We conducted a prospective phase II study for the evaluation of partial splenic embolization in patients with thrombocytopenia that impeded systemic chemotherapy continuation. From August 2014 through July 2015, 33 patients underwent partial splenic embolization to increase platelets count and allow their return to treatment. Primary endpoint was the accomplishment of a thrombocyte level superior to 130 × 109/L and the secondary endpoints were the return to chemotherapy and toxicity. Partial splenic embolization was done 36 times in 33 patients. All patients presented gastrointestinal cancer and colorectal malignancy was the commonest primary site. An average of 6.4 cycles of chemotherapy was done before splenic embolization and the most common regimen was Folfox. Mean platelet count prior to embolization was 69 × 109/L. A total of 94% of patients achieved primary endpoint. All patients in need reinitiated treatment and median time to chemotherapy return was 14 days. No grade 3 or above adverse events were identified. Aiming for a 50% to 70% infarction area may be sufficient to achieve success without the complications associated with more extensive infarction. Combined with the better safety profile, partial splenic embolization is an excellent option in the management of thrombocytopenia, enabling the resumption of systemic chemotherapy with minimal procedure‐related morbidity.
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Affiliation(s)
- Jose Hugo M Luz
- Department of Interventional Radiology, Radiology Division, National Cancer Institute, INCA, Rio de Janeiro, Brazil.
| | - Paula M Luz
- National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Edson Marchiori
- Department of Radiology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leonardo A Rodrigues
- Department of Interventional Radiology, Radiology Division, National Cancer Institute, INCA, Rio de Janeiro, Brazil
| | - Hugo R Gouveia
- Department of Interventional Radiology, Radiology Division, National Cancer Institute, INCA, Rio de Janeiro, Brazil
| | - Henrique S Martin
- Department of Interventional Radiology, Radiology Division, National Cancer Institute, INCA, Rio de Janeiro, Brazil
| | - Igor M Faria
- Department of Interventional Radiology, Radiology Division, National Cancer Institute, INCA, Rio de Janeiro, Brazil
| | - Roberto R Souza
- Department of Interventional Radiology, Radiology Division, National Cancer Institute, INCA, Rio de Janeiro, Brazil
| | - Roberto de Almeida Gil
- Department of Clinical Oncology, National Cancer Institute, INCA, Rio de Janeiro, Brazil
| | | | - Karina B Pimenta
- Department of Anesthesiology, National Cancer Institute, INCA, Rio de Janeiro, Brazil
| | - Henrique S de Souza
- Department of Interventional Radiology, Radiology Division, National Cancer Institute, INCA, Rio de Janeiro, Brazil
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27
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Flanagan E, Ghaderi I, Overby DW, Farrell TM. Reduced Survival in Bariatric Surgery Candidates Delayed or Denied by Lack of Insurance Approval. Am Surg 2016. [DOI: 10.1177/000313481608200222] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Bariatric surgery reduces mortality for Americans who meet candidacy criteria and have insurance coverage. Unfortunately, some medically suitable candidates are denied or delayed during insurance approval processes. The long-term impact of such care delays on survival is unknown. Using a prospectively maintained bariatric intake database, we identified consecutive applicants who were evaluated and medically cleared by our multidisciplinary care team and for whom insurance approval was requested. We compared survival in those who were initially approved by their insurance carriers (controls) and those who were initially denied coverage (subjects). Mortality was determined using the Social Security Death Index. Kaplan–Meier survival curves were plotted and the log-rank test for significance was applied. From August 2003 to December 2008, 463 patients (391 females, mean age 45 ± 10 years, mean body mass index 52.5 ± 9.4 kg/m2) were medically cleared for a bariatric procedure. Of these, 363 were approved by insurance on initial request, whereas 100 were denied. Given the study's intention to measure the aggregate impact of delays and denials, nine patients who later came to operation after appeal or coverage change were maintained in the subject cohort. During 0- to 113-month follow-up, six subjects (6%) died compared with seven controls (1.9%), corresponding to a statistically significant survival benefit for patients initially approved for bariatric surgery without delay or denial ( P < 0.001). In conclusion, access to bariatric surgical care was impeded by insurance certification processes in 22 per cent of medically acceptable candidates. Processes that delay or restrict efficient access to bariatric surgery are associated with a 3-fold mortality increase.
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Affiliation(s)
- Eleisha Flanagan
- From the Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Iman Ghaderi
- From the Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - D. Wayne Overby
- From the Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Timothy M. Farrell
- From the Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Efficacy and safety of anticoagulation therapy with different doses of enoxaparin for portal vein thrombosis in cirrhotic patients with hepatitis B. Eur J Gastroenterol Hepatol 2015; 27:914-9. [PMID: 25856686 DOI: 10.1097/meg.0000000000000351] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with cirrhosis have a high incidence of portal vein thrombosis (PVT), and optimal management of PVT in cirrhotic patients remains unclear. Currently, there is no paper on optimal doses of enoxaparin for the management of PVT with cirrhosis. AIMS To evaluate the efficacy and safety of anticoagulation therapy with different doses of enoxaparin for PVT in cirrhotic patients with hepatitis B. MATERIALS AND METHODS Sixty-five patients with hepatitis B-related cirrhosis and acute PVT were treated by different doses of enoxaparin. All the patients were assigned randomly to two groups: one group received enoxaparin 1 mg/kg subcutaneously every 12 h and the other group received enoxaparin 1.5 mg/kg subcutaneously every 24 h. Clinical, biochemical evaluation, Doppler ultrasound, and contrast-enhanced computed tomography were performed during the anticoagulation treatment. RESULTS Of the 65 patients, 51 patients (78.5%) achieved complete/partial recanalization of PVT after 6 months of anticoagulation therapy. Child-Pugh scores were lower in the 51 patients who achieved complete/partial recanalization than those of the 14 nonresponders (P<0.01). No patients showed variceal bleeding during anticoagulation therapy in the two groups. The rates of nonvariceal bleeding with the use of 1.5 mg/kg every 24 h (23.5%) were higher than those with the use of 1 mg/kg every 12 h (6.4%). CONCLUSION Anticoagulation therapy with different doses of enoxaparin for PVT in hepatitis B patients with cirrhosis is efficient and safe, and 1 mg/kg enoxaparin subcutaneously every 12 h is a better anticoagulation regimen in the treatment of PVT in cirrhotic patients.
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Bhatia SS, Venkat S, Echenique A, Rocha-Lima C, Doshi MH, Salsamendi J, Barbery K, Narayanan G. Proximal Splenic Artery Embolization in Chemotherapy-Induced Thrombocytopenia: A Retrospective Analysis of 13 Patients. J Vasc Interv Radiol 2015; 26:1205-11. [DOI: 10.1016/j.jvir.2015.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 04/01/2015] [Accepted: 04/02/2015] [Indexed: 01/14/2023] Open
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30
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Cai M, Huang W, Lin C, Li Z, Qian J, Huang M, Zeng Z, Huang J, Shan H, Zhu K. Partial splenic embolization for thrombocytopenia in liver cirrhosis: predictive factors for platelet increment and risk factors for major complications. Eur Radiol 2015; 26:370-80. [DOI: 10.1007/s00330-015-3839-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 04/07/2015] [Accepted: 05/08/2015] [Indexed: 01/17/2023]
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31
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Zhou J, Yang JH. Progress in treatment of nontumoral portal vein thrombosis in liver cirrhosis. Shijie Huaren Xiaohua Zazhi 2015; 23:735-740. [DOI: 10.11569/wcjd.v23.i5.735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) is not uncommon in patients with liver cirrhosis, and it increases the risk of gastroesophageal hemorrhage. At present, pharmacological treatment is the preferred selection of management of PVT. Studies have shown that anticoagulation therapy does not increase the risk of gastrointestinal bleeding. Therefore, patients having indications should be given anticoagulation therapy as early as possible. When patients fail to respond to anticoagulation therapy, interventional therapy or surgery may be considered. This article reviews the recent knowledge about the treatment of PVT and discusses the progress in treatment of nontumoral PVT in liver cirrhosis.
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