1
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Wu W, Zhang H, Zeng Z, Wang X, Kong D. Comparison of transjugular intrahepatic portosystemic with endoscopic treatment plus anticoagulation for esophageal variceal bleeding and portal vein thrombosis in liver cirrhosis. Scand J Gastroenterol 2022; 57:1494-1502. [PMID: 35802771 DOI: 10.1080/00365521.2022.2094724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM The optimal management of esophageal variceal bleeding (EVB) and portal vein thrombosis (PVT) in liver cirrhosis has not been well-established. The aim of the present study was to compare the efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) and endoscopic treatment (ET) plus anticoagulation in cirrhotic patients with EVB and PVT. PATIENTS AND METHODS A total of 66 cirrhotic patients with PVT and EVB (31 in the TIPS group and 35 in the ET plus anticoagulation group) were evaluated retrospectively between January 2016 and January 2022. RESULTS During the follow-up period, 85.5% of patients in the TIPS group achieved complete recanalization of the portal vein, as compared with 19.6% in the ET plus anticoagulation group (p < .001). The cumulative 5-year rate of variceal rebleeding in the TIPS group was significantly lower than that in the ET plus anticoagulation group (31.0 vs. 50.1%; p = .017). The TIPS group exhibited a significantly higher incidence of overt hepatic encephalopathy (HE) than the ET plus anticoagulation group (25.8 vs. 5.7%; p = .037). No difference in the 5-year survival rate (74.1 vs. 85.7%; p = .692) and probability of other complications was observed between the two groups. CONCLUSION TIPS was superior to ET plus anticoagulation in preventing variceal rebleeding and achieving recanalization of PVT but increased the incidence of overt HE without improving the survival rate.
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Affiliation(s)
- Wenyue Wu
- Department of Gastroenterology, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hejiao Zhang
- Department of Gastroenterology, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhuang Zeng
- Department of Gastroenterology, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xi Wang
- Department of Gastroenterology, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Derun Kong
- Department of Gastroenterology, the First Affiliated Hospital of Anhui Medical University, Hefei, China
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2
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Yeoh SW, Kok HK. Transjugular intrahepatic portosystemic shunts in portal vein thrombosis: A review. J Dig Dis 2021; 22:506-519. [PMID: 34323378 DOI: 10.1111/1751-2980.13035] [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: 04/17/2021] [Revised: 07/16/2021] [Accepted: 07/26/2021] [Indexed: 12/11/2022]
Abstract
The presence of portal vein thrombosis (PVT) has previously been considered a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS). However, patients with PVT may have portal hypertension complications and may thus benefit from TIPSS to reduce portal venous pressure. There is an increasing body of literature that discusses the techniques and outcomes of TIPSS in PVT. This review summarizes the techniques, indications and outcomes of TIPSS in PVT in published case reports, case series and comparative trials, especially regarding the reduction in portal hypertensive complications such as variceal bleeding. A comprehensive literature search was conducted using MEDLINE and PubMed databases. Manuscripts published in English between 1 January 1990 and 1 March 2021 were used. Abstracts were screened and data from potentially relevant articles analyzed. TIPSS in PVT has been reported with high levels of technical success, short-term portal vein recanalization and long-term PV patency and TIPSS patency outcomes. Several comparative studies, including randomized controlled trials, have shown favorable outcomes of TIPSS compared with non-TIPSS treatment of PVT complications. Outcomes of TIPSS with PVT appear similar to those in TIPSS without PVT. However, TIPSS may be more technically difficult in the presence of PVT, and such procedures should be performed in expert high-volume centers to mitigate the risk of procedural complications. The presence of PVT should no longer be considered a contraindication to TIPSS. TIPSS for PVT has been acknowledged as a therapeutic strategy in recent international guidelines, although further studies are needed before recommendations can be strengthened. KEY POINTS: Portal vein thrombosis (PVT) is no longer a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS) TIPSS often leads to the spontaneous dissolution of PVT, but can be combined with mechanical or pharmacological thrombectomy TIPSS reduces portal hypertensive complications of PVT, such as variceal bleeding, and can also facilitate liver transplantation where PVT may otherwise interfere with vascular anastomoses Studies have shown favorable long-term outcomes of TIPSS compared with TIPSS without PVT; as well as compared with non-TIPSS treatment of PVT complications TIPSS in PVT should be performed in high-volume specialist centers due to technical difficulties.
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Affiliation(s)
- Sern Wei Yeoh
- Department of Gastroenterology, Northern Health, Melbourne, Victoria, Australia.,School of Medical Education, University of Melbourne, Melbourne, Victoria, Australia
| | - Hong Kuan Kok
- Department of Radiology, Northern Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Melbourne, Victoria, Australia
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3
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Abstract
Portal vein thrombosis (PVT) is one of the common complications of liver cirrhosis, which can further increase portal vein pressure and aggravate liver function decompensation. However, due to the insidious onset and atypical symptoms, the importance of PVT has been neglected in clinical work for quite a long time. With the development of clinical diagnostic technology, the detection rate of PVT has increased year by year. At present, the well-established treatment methods for PVT include anticoagulant therapy, interventional therapy, and surgical treatment. However, the optimal choice for PVT treatment remains unclear. In this paper, we briefly review the recent progress in the diagnosis and treatment of PVT in order to provide a theoretical reference for the refined clinical management of patients with PVT.
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Affiliation(s)
- Wen-Yue Wu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei 237000, Anhui Province, China
| | - De-Run Kong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei 237000, Anhui Province, China
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4
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Mancuso A. Controversies in the Management of Portal Vein Thrombosis in Liver Cirrhosis. J Clin Med 2020; 9:jcm9123916. [PMID: 33276635 PMCID: PMC7761540 DOI: 10.3390/jcm9123916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/01/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Andrea Mancuso
- Medicina Interna 1, ARNAS Civico-Di Cristina-Benfratelli, Piazza Leotta 4, 90100 Palermo, Italy
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5
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Efficacy and safety study of direct-acting oral anticoagulants for the treatment of chronic portal vein thrombosis in patients with liver cirrhosis. Eur J Gastroenterol Hepatol 2020; 32:1395-1400. [PMID: 32675774 DOI: 10.1097/meg.0000000000001846] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIMS This study is designed to investigate the efficacy and safety of direct-acting oral anticoagulants (DOACs) for the treatment of chronic portal vein thrombosis (PVT) in liver cirrhosis patients. MATERIALS AND METHODS In a prospective cohort study, patients were divided into DOACs group (oral rivaroxaban tablets or dabigatran etexilate capsules) and control group (no anticoagulant treatment). Based on propensity score matching method, 40 patients with cirrhosis and chronic PVT in each of the groups were recruited for this study. CT portal venography was used to monitor the portal vein area. Color Doppler ultrasound was used to monitor the portal vein flow rate. Biochemical testing and thromboelastography (TEG) were also used for monitoring the status of PVT. RESULTS After 3 months of DOACs treatment, the complete/partial recanalization rate of DOACs was 12.8% (5/39). After 6 months of DOACs treatment, the PVT complete/partial recanalization rate of DOACs was 28.2% (11/39). The recanalization rate and portal vein flow velocity improvement were higher than those in the control group (P < 0.05). Patients' total bilirubin level and Child-Pugh scores were improved in the DOACs group. The TEG coagulation index was lower in the DOACs group than in the control group (P < 0.05). There was no statistically significant difference between the DOACs group and control group in the cases of bleeding (P > 0.05). CONCLUSION DOACs are effective and safe for chronic PVT in patients with liver cirrhosis. The TEG can predict the risk of bleeding in patients with chronic PVT in cirrhosis, which is more sensitive than conventional coagulation function test.
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Nicoară-Farcău O, Soy G, Magaz M, Baiges A, Turon F, Garcia-Criado A, Barrufet M, Burrel M, Hernández-Gea V, García-Pagán JC. New Insights into the Pathogenesis, Risk Factors, and Treatment of Portal Vein Thrombosis in Patients with Cirrhosis. Semin Thromb Hemost 2020; 46:673-681. [PMID: 32820481 DOI: 10.1055/s-0040-1715473] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis (PVT) is a frequent event in patients with cirrhosis regardless of etiology. Notwithstanding the commonality of the problem, the pathophysiology and risk factors for PVT in cirrhosis are largely unknown. The clinical impact of PVT in the natural history of cirrhosis is unclear, indications for PVT treatment are not well defined, and treatment recommendations are based on experts' opinion and consensus only. Therefore, this review aims to summarize current knowledge of mechanisms and risk factors for PVT development and assess the current evidence of PVT management, with a special focus on strategies of anticoagulation and transjugular intrahepatic portosystemic shunt placement.
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Affiliation(s)
- Oana Nicoară-Farcău
- Department of Hepatology, Regional Institute of Gastroenterology and Hepatology "Octavian Fodor," "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Guillem Soy
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Marta Magaz
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Anna Baiges
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Fanny Turon
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Angeles Garcia-Criado
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver).,Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Marta Barrufet
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver).,Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Marta Burrel
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver).,Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Virginia Hernández-Gea
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Juan Carlos García-Pagán
- Liver Unit, Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
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7
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Exploration of interventional therapy strategy for portal vein occlusion: a case series study. Eur J Gastroenterol Hepatol 2020; 32:507-516. [PMID: 31658174 DOI: 10.1097/meg.0000000000001586] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To explore the candidates, efficacy and safety of interventional therapies in the treatment of portal vein occlusion (PVO). METHODS In our study, 13 patients diagnosed with PVO were included. Of all 13 patients, two received percutaneous portal vein recanalization (PVR), 10 received PVR and transjugular intrahepatic portosystemic shunt (PVR-TIPS), and one underwent intrahepatic portal branch-large collateral vessel shunt. RESULTS Interventional approaches were completed in all patients, and the technical success rate was 100%. The portal pressure gradient of patients treated with PVR-TIPS fell from 31 ± 4 to 12 ± 3 mmHg. During the procedures, no life-threatening complications occurred. All the clinical symptoms were effectively controlled after the interventional therapies and all the patients survived during the follow-up, with no rebleeding or overt hepatic encephalopathy. But stent thrombosis occurred in one patient, the cumulative rate of stent patency was 92%. CONCLUSION Interventional therapy was proved to be a well tolerated and effective strategy for PVO. For PVO patients without high intrahepatic resistance, if the patient is equipped with available portal inflow tract (superior mesenteric vein or splenic vein) and outflow tract (intrahepatic portal branches), PVR is the first choice; if the outflow tract is completely blocked with only available inflow tract, PVR-TIPS can be considered. For PVO patients with high intrahepatic resistance, as long as there is an available portal inflow tract, PVR-TIPS can be adopted.
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8
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Abstract
Non-tumoral portal vein thrombosis (PVT) remains a highly relevant topic in the field of hepatology and liver transplantation with much surrounding controversy. Although multiple studies have shown that PVT is associated with adverse outcomes with increased morbidity and mortality rates, others have not reported the same clinical impact of PVT, arguing rather that incident PVT reflects worsening portal hypertension and the natural history of the disease. Despite this uncertainly, PVT is a dilemma facing the clinician on a daily basis often requiring a multidisciplinary team-based approach between hepatologists, transplant surgeons, interventional radiologists and hematologists. In this review, the authors provide a summary of the evidence supporting best clinical practices in the management of non-tumoral PVT in patients with cirrhosis.
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Affiliation(s)
- Jonathan G Stine
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
- Department of Public Health Sciences, The Pennsylvania State University Milton S. Hershey Medical Center, Hershey, PA, USA.
| | - Patrick G Northup
- Department of Medicine, Center for the Study of Coagulation Disorders in Liver Disease, Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
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9
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Couri T, Harmath C, Baker T, Pillai A. Acute portal vein thrombosis after liver transplant presenting with subtle ultrasound abnormalities: A case report and literature review. World J Hepatol 2019; 11:234-241. [PMID: 30820273 PMCID: PMC6393712 DOI: 10.4254/wjh.v11.i2.234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 11/27/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Portal vein thrombosis (PVT) after liver transplantation (LT) is an uncommon complication with potential for significant morbidity and mortality that transplant providers should be cognizant of. Recognizing subtle changes in post-operative ultrasounds that could herald but do not definitively diagnose PVT is paramount.
CASE SUMMARY A 30-year-old female with a history of alcohol-related cirrhosis presented with painless jaundice and received a deceased donor orthotopic liver transplant. On the first two days post-operatively, her liver Doppler ultrasounds showed a patent portal vein, increased hepatic arterial diastolic flows, and reduced hepatic arterial resistive indices. She was asymptomatic with improving labs. On post-operative day three, her resistive indices declined further, and computed tomography of the abdomen revealed a large extra-hepatic PVT. The patient then underwent emergent percutaneous venography with tissue plasminogen activator administration, angioplasty, and stent placement. Aspirin was started to prevent stent thrombosis. Follow-up ultrasounds showed a patent portal vein and improved hepatic arterial resistive indices. Her graft function improved to normal by discharge. Although decreased hepatic artery resistive indices and increased diastolic flows on ultrasound are often associated with hepatic arterial stenosis post-LT, PVT can also cause these findings.
CONCLUSION Reduced hepatic arterial resistive indices on ultrasound can signify PVT post-LT, and thrombolysis, angioplasty, and stent placement are efficacious treatments.
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Affiliation(s)
- Thomas Couri
- Department of Internal Medicine, University of Chicago, Chicago, IL 60637, United States
| | - Carla Harmath
- Department of Radiology, University of Chicago, Chicago, IL 60637, United States
| | - Talia Baker
- Department of Surgery, Section of Transplant Surgery, University of Chicago, Chicago, IL 60637, United States
| | - Anjana Pillai
- Department of Internal Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, IL 60637, United States
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10
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Zanetto A, Rodriguez-Kastro KI, Germani G, Ferrarese A, Cillo U, Burra P, Senzolo M. Mortality in liver transplant recipients with portal vein thrombosis - an updated meta-analysis. Transpl Int 2018; 31:1318-1329. [DOI: 10.1111/tri.13353] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 04/20/2018] [Accepted: 09/13/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Alberto Zanetto
- Multivisceral Transplant Unit; Department of Surgery, Oncology and Gastroenterology; Padua University Hospital; Padua Italy
| | | | - Giacomo Germani
- Multivisceral Transplant Unit; Department of Surgery, Oncology and Gastroenterology; Padua University Hospital; Padua Italy
| | - Alberto Ferrarese
- Multivisceral Transplant Unit; Department of Surgery, Oncology and Gastroenterology; Padua University Hospital; Padua Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit; Department of Surgery, Oncology and Gastroenterology; Padua University Hospital; Padua Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit; Department of Surgery, Oncology and Gastroenterology; Padua University Hospital; Padua Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit; Department of Surgery, Oncology and Gastroenterology; Padua University Hospital; Padua Italy
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11
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12
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The keys to successful TIPS in patients with portal vein thrombosis and cavernous transformation. RADIOLOGIA 2018. [DOI: 10.1016/j.rxeng.2018.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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13
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Mancuso A, Politi F, Maringhini A. Portal Vein Thromboses in Cirrhosis: To Treat or Not to Treat? Gastroenterology 2018; 154:758. [PMID: 29352958 DOI: 10.1053/j.gastro.2017.07.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 07/13/2017] [Indexed: 12/02/2022]
Affiliation(s)
- Andrea Mancuso
- Medicina Interna 1, ARNAS Civico - Di Cristina - Benfratelli, Palermo, Italy
| | - Flavia Politi
- Medicina Interna 1, ARNAS Civico - Di Cristina - Benfratelli, Palermo, Italy
| | - Alberto Maringhini
- Medicina Interna 1, ARNAS Civico - Di Cristina - Benfratelli, Palermo, Italy
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14
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The keys to successful TIPS in patients with portal vein thrombosis and cavernous transformation. RADIOLOGIA 2017; 60:94-104. [PMID: 29122309 DOI: 10.1016/j.rx.2017.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 08/08/2017] [Accepted: 08/10/2017] [Indexed: 12/22/2022]
Abstract
Portal vein thrombosis is a common complication in patients with cirrhosis. Anticoagulation involves a high risk of bleeding secondary to portal hypertension, so placing transjugular intrahepatic portosystemic shunts (TIPS) has become an alternative treatment for portal vein thrombosis. Three strategies for TIPS placement have been reported: 1) portal recanalization and conventional implantation of the TIPS through the jugular vein; 2) portal recanalization through percutaneous transhepatic/transsplenic) access; and (3) insertion of the TIPS between the suprahepatic vein and a periportal collateral vessel without portal recanalization. We describe different materials that can be used as fluoroscopic targets for the TIPS needle and for portal recanalization. This article aims to show the success of TIPS implantation using different combinations of the techniques listed above, which is a good treatment alternative in these patients whose clinical condition makes them difficult to manage, and to show that portal vein thrombosis/cavernous transformation should not be considered a contraindication for TIPS.
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15
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Zhang ZH, Zhang JW, He P, Zhou Y, Sun CY. Fondaparinux is effective for acute portal vein thrombosis in decompensated cirrhotic patients. Medicine (Baltimore) 2017; 96:e8256. [PMID: 29049216 PMCID: PMC5662382 DOI: 10.1097/md.0000000000008256] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) is a rare but serious complication in the decompensated stage of cirrhosis, and recurrent upper gastrointestinal bleeding and refractory ascites can occur in such patients. In decompensated cirrhotic patients, the application of conventional anticoagulant therapy is limited due to severe coagulation disorders, thrombocytopenia, and history of gastrointestinal bleeding.In this study, we sought to investigate the effect of fondaparinux on acute PVT in decompensated cirrhotic patients.Patients were treated with fondaparinux (2.5 mg, q 24 h, subcutaneously) in the region of the umbilicus for conventional liver protection, after a clear diagnosis was made and contraindications such as active bleeding were ruled out. Other anticoagulants and circulation-improving drugs were not administered. Platelet count, prothrombin time, international normalized ratio, D dimer (DD), and liver function were measured. Furthermore, portal vein color Doppler ultrasound was performed every 7 days while patients were treated with fondaparinux and after portal vein recanalization.The portal vein was recanalized in all patients after treatment (P = .018). The decline in DD had a predictive value for portal vein recanalization (P = .018). No side effects such as bleeding or thrombocytopenia occurred in any of the patients (P > .05).Selective factor Xa inhibitor fondaparinux is effective and safe for acute PVT in decompensated cirrhotic patients.
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Affiliation(s)
- Zhi-Hao Zhang
- Department of Infectious Diseases Department of Geriatric Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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16
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17
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Mancuso A. Classification of Portal Vein Thrombosis in Cirrhosis. Gastroenterology 2017; 152:1247. [PMID: 28264766 DOI: 10.1053/j.gastro.2016.09.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/27/2016] [Indexed: 01/16/2023]
Affiliation(s)
- Andrea Mancuso
- Medicina Interna 1, ARNAS Civico - Di Cristina - Benfratelli, Palermo and Epatologia e Gastroenterologia, Ospedale Niguarda Ca' Granda, Milano, Italy
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18
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Sharma AK, Kaufman DC. TIPS performed in a patient with complete portal vein thrombosis. Radiol Case Rep 2017; 12:327-330. [PMID: 28491181 PMCID: PMC5417740 DOI: 10.1016/j.radcr.2017.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 01/12/2017] [Accepted: 01/13/2017] [Indexed: 11/30/2022] Open
Abstract
Portal vein thrombosis is common in cirrhotic patients and results in increased morbidity and mortality. Transjugular intrahepatic portosystemic shunt (TIPS) creation is a well-established therapy for refractory variceal bleeding and refractory ascites in patients who do not tolerate repeated large volume paracentesis. Experience and technical improvements have led to improved TIPS outcomes that have encouraged an expanded application. Complete portal vein thrombosis has come a long way from being a contraindication to an indication for TIPS procedure. As experience and technology have evolved, the ultrasound guidance transvenous access of portal vein from the hepatic vein help in overall higher success rate of performing the TIPS procedure and reducing the procedure-related complications.
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Affiliation(s)
- Ashwani Kumar Sharma
- Interventional Radiology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - David Charles Kaufman
- Surgery, Medicine, Anesthesia, Urology and Medical Humanities and Bioethics, University of Rochester Medical Center, Rochester, NY, USA
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19
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Mancuso A. Management of portal vein thrombosis in cirrhosis: More shadows than lights. Dig Liver Dis 2017; 49:228. [PMID: 27053401 DOI: 10.1016/j.dld.2016.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 03/15/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Andrea Mancuso
- Medicina Interna 1, ARNAS Civico - Di Cristina - Benfratelli, Palermo, Italy; Epatologia e Gastroenterologia, Ospedale Niguarda Ca' Granda, Milano, Italy.
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20
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Mancuso A. The ischemic liver cirrhosis theory and its clinical implications. Med Hypotheses 2016; 94:4-6. [PMID: 27515188 DOI: 10.1016/j.mehy.2016.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/02/2016] [Accepted: 06/08/2016] [Indexed: 12/26/2022]
Abstract
The canonical pathway theory of cirrhosis addresses inflammation as the main driver of hepatic fibrogenesis in hepatitis, so needing a further hypothesis for etiologies missing inflammation, for which parenchymal extinction is postulated. The present paper reports an alternative hypothesis suggesting a central role of micro-vascular ischemia in fibrogenesis and cirrhosis development, whatever is the aetiology of liver chronic injury. In fact, since chronic liver injury could finally result in endothelial damage and micro-vascular thrombosis, leading to a trigger of inappropriate hepatocyte proliferation and fibrosis, finally cirrhosis development could arise from chronic micro-vascular ischemia. Recently, some important confirmation of this hypothesis has been reported. In fact, in a murine experimental model of congestive hepatopathy, it was found that chronic hepatic congestion leads to sinusoidal thrombosis and strain, which in turn promote hepatic fibrosis. Furthermore, a study on a murine model of cirrhosis reported enoxaparin to reduce hepatic vascular resistance and portal pressure by having a protective role against fibrogenesis. In conclusion, the hypothesis giving a central role of micro-vascular ischemia in fibrogenesis and cirrhosis development could change the clinical scenario of chronic liver disease and have several main implications on management of various liver disease.
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Affiliation(s)
- Andrea Mancuso
- Medicina Interna 1, ARNAS Civico - Di Cristina - Benfratelli, Piazzale Liotti 4, Palermo, Italy; Epatologia e Gastroenterologia, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore 3, 20162 Milano, Italy.
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