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Valla DC. Hepatic vein thrombosis and PVT: A personal view on the contemporary development of ideas. Clin Liver Dis (Hoboken) 2024; 23:e0246. [PMID: 38988821 PMCID: PMC11236412 DOI: 10.1097/cld.0000000000000246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/10/2024] [Indexed: 07/12/2024] Open
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Tie J, Gou X, He C, Li K, Yuan X, Jia W, Niu J, Han N, Xu J, Zhu Y, Wang W. Transjugular intrahepatic collateral-systemic shunt is effective for cavernous transformation of the portal vein with variceal bleeding. Hepatol Int 2023; 17:979-988. [PMID: 37097537 PMCID: PMC10386942 DOI: 10.1007/s12072-023-10522-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/13/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND The transjugular intrahepatic portal collateral-systemic shunt (transcollateral TIPS) is used to treat portal hypertension-related complications in patients with cavernous transformation of the portal vein (CTPV) and whose main portal vein cannot be recanalized. It is still not clear whether transcollateral TIPS can be as effective as portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS). This study aimed to evaluate the efficacy and safety of transcollateral TIPS in the treatment of refractory variceal bleeding with CTPV. METHODS Patients with refractory variceal bleeding caused by CTPV were selected from the database of consecutive patients treated with TIPS in Xijing Hospital from January 2015 to March 2022. They were divided into the transcollateral TIPS group and the PVR-TIPS group. The rebleeding rate, overall survival, shunt dysfunction, overt hepatic encephalopathy (OHE) and operation-related complications were analyzed. RESULTS A total of 192 patients were enrolled, including 21 patients with transcollateral TIPS and 171 patients with PVR-TIPS. Compared with the patients with PVR-TIPS, the patients with transcollateral TIPS had more noncirrhosis (52.4 vs. 19.9%, p = 0.002), underwent fewer splenectomies (14.3 vs. 40.9%, p = 0.018), and had more extensive thromboses (38.1 vs. 15.2%, p = 0.026). There were no differences in rebleeding, survival, shunt dysfunction, or operation-related complication rates between the transcollateral TIPS and PVR-TIPS groups. However, the OHE rate was significantly lower in the transcollateral TIPS group (9.5 vs. 35.1%, p = 0.018). CONCLUSION Transcollateral TIPS is an effective treatment for CTPV with refractory variceal bleeding.
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Affiliation(s)
- Jun Tie
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China.
| | - Xiaoyuan Gou
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Chuangye He
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Kai Li
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Xulong Yuan
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Wenyuan Jia
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Jing Niu
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Na Han
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Jiao Xu
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Ying Zhu
- National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Wenlan Wang
- Department of Aerospace Hygiene, School of Aerospace Medicine, Air Force Medical University, Xi'an, 710032, Shaanxi, China.
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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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Elkrief L, Payancé A, Plessier A, d’Alteroche L, Ronot M, Paradis V, Valla D, Rautou PE. Management of splanchnic vein thrombosis. JHEP Rep 2023; 5:100667. [PMID: 36941824 PMCID: PMC10023986 DOI: 10.1016/j.jhepr.2022.100667] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 12/11/2022] [Accepted: 12/23/2022] [Indexed: 01/04/2023] Open
Abstract
The expression splanchnic vein thrombosis encompasses Budd-Chiari syndrome and portal vein thrombosis. These disorders have common characteristics: they are both rare diseases which can cause portal hypertension and its complications. Budd-Chiari syndrome and portal vein thrombosis in the absence of underlying liver disease share many risk factors, among which myeloproliferative neoplasms represent the most common; a rapid comprehensive work-up for risk factors of thrombosis is needed in these patients. Long-term anticoagulation is indicated in most patients. Portal vein thrombosis can also develop in patients with cirrhosis and in those with porto-sinusoidal vascular liver disease. The presence and nature of underlying liver disease impacts the management of portal vein thrombosis. Indications for anticoagulation in patients with cirrhosis are growing, while transjugular intrahepatic portosystemic shunt is now a second-line option. Due to the rarity of these diseases, studies yielding high-grade evidence are scarce. However, collaborative studies have provided new insight into the management of these patients. This article focuses on the causes, diagnosis, and management of patients with Budd-Chiari syndrome, portal vein thrombosis without underlying liver disease, or cirrhosis with non-malignant portal vein thrombosis.
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Key Words
- BCS, Budd-Chiari syndrome
- CALR, calreticulin
- Cavernoma
- DOACs, direct-acting oral anticoagulants
- Direct oral anticoagulants
- EHPVO, extrahepatic portal vein obstruction
- GFR, glomerular filtration rate
- JAK2, Janus kinase 2
- LMWH, low-molecular-weight heparin
- MPN, myeloproliferative neoplasm
- MTHFR, methylene-tetrahydrofolate reductase
- PNH, paroxysmal nocturnal hemoglobinuria
- PVT, portal vein thrombosis
- Portal biliopathy
- Portal vein recanalisation
- SVT, splanchnic vein thrombosis
- TIPS, transjugular intrahepatic portosystemic shunt
- VKAs, vitamin K antagonists
- Vascular liver diseases
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Affiliation(s)
- Laure Elkrief
- Service d’Hépato-Gastroentérologie CHU de Tours, France
| | - Audrey Payancé
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Aurélie Plessier
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | | | - Maxime Ronot
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service de radiologie, Hôpital Beaujon APHP.Nord, Clichy, France
| | - Valérie Paradis
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d’anatomie et cytologie pathologique, Hôpital Beaujon APHP.Nord, Clichy, France
| | - Dominique Valla
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Pierre-Emmanuel Rautou
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
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Primary Catheter-Directed Thrombolysis for Porto-Mesenteric Venous Thrombosis (PMVT) in Non-Cirrhotic Patients. J Clin Med 2022; 11:jcm11164721. [PMID: 36012959 PMCID: PMC9409877 DOI: 10.3390/jcm11164721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/01/2022] [Accepted: 08/08/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose: To report our thrombolytic technique, treatment strategy, and clinical outcomes for porto-mesenteric venous thrombosis (PMVT) in non-cirrhotic patients. Methods: Sixteen acute or chronic non-cirrhotic PMVT patients (mean age: 48.6 years) with imminent intestinal ischemia were enrolled from 2004 to 2020. Eight patients presented thrombus extension into the peripheral mesenteric vein, close to the venous arcade. Transhepatic catheter-directed thrombolysis (CDT) was performed by urokinase infusion (60,000–30,000 IU/h concomitant with heparin 300–400 IU/h), catheter aspiration, and/or balloon dilation/stent placement. Additional intra-arterial mesenteric infusion of urokinase (30,000 IU/h) was given in patients with the peripheral mesenteric venules involved. Transjugular intrahepatic porto-systemic shunt (TIPS) was created in patients with poor recanalization of the intrahepatic portal flow (PV). Results: The transhepatic route was adopted in all patients, with adjunct indirect mesenteric arterial thrombolytic infusion in eight patients. A total of up to 20.4 million IU urokinase was infused for 1–21 days’ treatment duration. TIPS was created in three patients with recanalization failure of the intrahepatic PV. Technical success was achieved in 100% of patients with complete recanalization of 80% and partial recanalization of 20%. No major procedure-related complications were encountered. The 30-day mortality rate was 6.7%. The overall two-year primary patency was 84.6%. Conclusions: CDT can be performed as a primary salvage treatment once the diagnosis is made. CDT via the transhepatic route with tailored thrombolytic regimen is safe and effective for both acute and chronic PMVT. TIPS creation can be preserved in non-cirrhotic PMVT patients if intrahepatic PV recanalization fails.
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Retrospective evaluation of early thrombosis in transjugular intrahepatic portosystemic polytetrafluoroethylene-coated shunts under 2-day postinterventional heparinization. Sci Rep 2022; 12:10506. [PMID: 35732875 PMCID: PMC9217914 DOI: 10.1038/s41598-022-14388-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 06/06/2022] [Indexed: 11/08/2022] Open
Abstract
The development of acute thrombosis within the TIPS tract may be prevented by prophylactic anticoagulation; however, there is no evidence of the correct anticoagulation regimen after TIPS placement. The purpose of this single-center retrospective study was to evaluate the short-term occlusion rate of transjugular intrahepatic portosystemic shunts (TIPSs) with polytetrafluorethylene (PTFE)-coated stents under consequent periprocedural full heparinization (target partial thromboplastin time [PTT]: 60–80 s). We analyzed TIPS placements that were followed up over a six-month period by Doppler ultrasound in 94 patients and compared the study group of 54 patients who received intravenous periprocedural full heparinization (target PTT: 60–80 s) without any other anticoagulation to patients with prolonged anticoagulation medication. The primary endpoint was TIPS patency after six months. The primary patency rate was 88.3% overall, and in the study group, 90.7%, with an early thrombosis rate of 3.2% (study group: 1.9%) and a primary assisted patency rate of 95.7% (study group: 96.3%). In the study group, one case of TIPS thrombosis occurred on the 23rd day after TIPS placement. Two patients underwent reintervention because of stenosis or buckling. Moreover, the target PTT was not attained in 8 of the 54 patent TIPSs. Four patients had an increased portosystemic pressure gradient, without stenosis, and the flow rate was corrected by increasing the TIPS diameter by dilation. Two-day heparinization seems sufficient to avoid early TIPS thrombosis over a six-month period.
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Vermersch M, Denys A, Artru F, Tsoumakidou G, Villard N, Duran R, Hocquelet A. Transhepatic tract hemostasis using thermal-ablation after percutaneous portal vein access. BJR Case Rep 2022; 8:20210080. [PMID: 35136636 PMCID: PMC8803226 DOI: 10.1259/bjrcr.20210080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 08/13/2021] [Accepted: 08/24/2021] [Indexed: 01/10/2023] Open
Abstract
Objectives: Bleeding risk after percutaneous portal vein access procedures is not negligible. Various agents, coils and plug, have been used to minimize this risk, each with their own advantages and disadvantages. This study reports the results of coagulation using thermal-ablation (radiofrequency or microwave ablation) as an alternative to trans-hepatic puncture tract closure. Methods: Ten patients who benefited from portal vein recanalization or portal hypertension-relative bleeding complication embolization using percutaneous portal vein access and who underwent thermal-ablation of the puncture tract between December 30, 2019 and July 16, 2020 were included. Early efficiency and safety were evaluated using imaging (ultrasound and/or CT scan) and laboratory data (hemoglobin, hepatic function) at 24 h. Follow-up was performed until August 2020. Results: No bleeding from the puncture tract and no embolization-related complications were observed in all 10 patients at 24 h or during follow-up with median of 3 months (range 1–8 months), even in case of ascites or therapeutic coagulation. Conclusion: Thermal-ablation seems to be a safe, effective and rapid technique to avoid bleeding after percutaneous transhepatic direct portal vein access. Advances in knowledge: Thermal-ablation could be an alternative for transhepatic puncture tract closure especially for patients with high bleeding risk.
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Affiliation(s)
- Mathilde Vermersch
- Department of Radiology, Lausanne University Hospital CHUV, Lausanne, Switzerland
- Department or Radiology, Lille University Hospital, Lille, France
| | - Alban Denys
- Department of Radiology, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Florent Artru
- Department of Gastro-enterology, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Georgia Tsoumakidou
- Department of Radiology, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Villard
- Department of Radiology, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Rafael Duran
- Department of Radiology, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Arnaud Hocquelet
- Department of Radiology, Lausanne University Hospital CHUV, Lausanne, Switzerland
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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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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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Cannataci C, Cimo' B, Mamone G, Tuzzolino F, D'Amico M, Cortis K, Maruzzelli L, Miraglia R. Portal vein puncture-related complications during transjugular intrahepatic portosystemic shunt creation: Colapinto needle set vs Rösch-Uchida needle set. Radiol Med 2021; 126:1487-1495. [PMID: 34405340 DOI: 10.1007/s11547-021-01404-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 07/27/2021] [Indexed: 02/07/2023]
Abstract
Transjugular portal vein puncture is considered the riskiest step in TIPS creation with possible incidence of portal vein puncture-related complications (PVPC). The Colapinto and the Rösch-Uchida needle sets are two different needle sets currently available. To date, there have been no randomized control trials or systematic reviews which compare the incidence of PVPC when using the two different needle sets. The aim of this literature review is to assess the rate of PVPC associated with the different needle sets used in the creation of TIPS. From the described search, 1500 articles were identified and 34 met the inclusion criteria. Outcome measured was the prevalence of PVPC using the different needle sets. Overall 212 (3.6%) PVPC were reported in 5865 patients; 142 (3.5%) reported in 4000 cases using the Rösch-Uchida set and 70 (3.7%) in 1865 patients using the Colapinto set (p = 0.69). PVPC in TIPS creation are not related to the choice of needle set used in the procedure. To our knowledge, this is the first review of its kind, the results of which support the theory that while the rate of PVPC is influenced by many factors, choice of needle set does not seem to be one of them.
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Affiliation(s)
| | - Biagio Cimo'
- Radiology Institute, Department of Medicine - DIMED, University of Padua, Padova, Italy
| | - Giuseppe Mamone
- Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), via Tricomi 5, 90127, Palermo, Italy.
| | - Fabio Tuzzolino
- Research Office, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Mario D'Amico
- Azienda Ospedaliera Ospedali Riuniti Villa Sofia- Cervello, Palermo, Italy
| | - Kelvin Cortis
- Medical Imaging Department, Mater Dei Hospital, Msida, Malta
| | - Luigi Maruzzelli
- Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), via Tricomi 5, 90127, Palermo, Italy
| | - Roberto Miraglia
- Radiology Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), via Tricomi 5, 90127, Palermo, Italy
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11
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Zhang JB, Chen J, Zhou J, Wang XM, Chen S, Chu JG, Liu P, Ye ZD. Systematic review and meta-analysis of trans-jugular intrahepatic portosystemic shunt for cirrhotic patients with portal vein thrombosis. World J Clin Cases 2021; 9:5179-5190. [PMID: 34307565 PMCID: PMC8283597 DOI: 10.12998/wjcc.v9.i19.5179] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/21/2021] [Accepted: 04/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Portal vein thrombosis (PVT) was previously a contraindication for trans-jugular intrahepatic portosystemic shunt (TIPS).
AIM To perform a systematic review and meta-analysis of the current available studies investigating outcomes of TIPS for cirrhotic patient with PVT.
METHODS Multiple databases were systematically searched to identify studies investigating the outcomes of TIPS for cirrhotic patients with PVT. The quality of studies was assessed by Cochrane Collaboration method and Methodological Index for Non-Randomized Studies. The demographic data, outcomes, combined treatment, and anticoagulation strategy were extracted.
RESULTS Twelve studies were identified with 460 patients enrolled in the analysis. The technical success rate was 98.9% in patients without portal vein cavernous transformation and 92.3% in patients with portal vein cavernous transformation. One-year portal vein recanalization rate was 77.7%, and TIPS patency rate was 84.2%. The cumulative encephalopathy rate was 16.4%. One-year overall survival was 87.4%.
CONCLUSION TIPS is indicated for portal hypertension related complications and the restoration of pre-transplantation portal vein patency in cirrhotic patients with PVT. Cavernous transformation is an indicator for technical failure. Post-TIPS anticoagulation seems not mandatory. Simultaneous TIPS and percutaneous mechanical thrombectomy device could achieve accelerated portal vein recanalization and decreased thrombolysis-associated complications, but further investigation is still needed.
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Affiliation(s)
- Jian-Bin Zhang
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jie Chen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jin Zhou
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xu-Ming Wang
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Shu Chen
- Department of Interventional Radiology, Affiliated People’s Hospital of Inner Mongolia Medical University, Hohhot 010020, Inner Mongolia Autonomous Region, China
| | - Jian-Guo Chu
- Department of Radiology, Air Force Medical Center of PLA, Beijing 100142, China
| | - Peng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Zhi-Dong Ye
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing 100029, China
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12
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Sun XY, Wang GC, Wang J, Huang GJ, Zhang CQ. Transjugular intrahepatic portosystemic shunt is effective in patients with chronic portal vein thrombosis and variceal bleeding. Hepatobiliary Pancreat Dis Int 2021; 20:128-136. [PMID: 33455864 DOI: 10.1016/j.hbpd.2020.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 12/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Studies about treatment of patients with chronic portal vein thrombosis (CPVT) are still limited, especially in different types of CPVT. This study aimed to evaluate the effect of transjugular intrahepatic portosystemic shunt (TIPS) in all types of CPVT with variceal bleeding. METHODS Patients with CPVT who received TIPS treatment between January 2011 and June 2019 were divided into four types according to the extent of thrombosis. All patients had a history of variceal bleeding. The characteristics and clinical parameters were collected and recorded. Data on procedure success rate, variation in portal vein pressure, rebleeding, hepatic encephalopathy (HE), stent stenosis, and overall mortality were analyzed. RESULTS A total of 189 patients were included in this study (39 in type 1, 84 in type 2, 48 in type 3, 18 in type 4). The TIPS procedure success rate was 86.2%. The success rate was significantly different among the four types (89.7% vs. 88.1% vs. 83.3% vs. 77.8%, P = 0.001). In the TIPS success group, portal vein pressure was significantly reduced from 27.15 ± 6.59 to 19.74 ± 6.73 mmHg after the procedure (P < 0.001) and the rebleeding rate was significantly lower than that of the fail group (14.7% vs. 30.8%, P = 0.017). In addition, there were no significant differences in HE rate (30.7% vs. 26.9%, P = 0.912) or overall mortality (12.9% vs. 19.2%, P = 0.403) between the TIPS success group and the fail group. In the TIPS success group, we found that the occurrence of HE was significantly different (P = 0.020) among the four types, while there were no significant differences in rebleeding rate (P = 0.669), stent stenosis rate (P = 0.056), or overall mortality (P = 0.690). CONCLUSIONS TIPS was safe and effective in decreasing portal vein pressure and rebleeding rate in patients with CPVT.
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Affiliation(s)
- Xiao-Yan Sun
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Guang-Chuan Wang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Jing Wang
- Department of Infectious Diseases, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Guang-Jun Huang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Chun-Qing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China.
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13
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Niu XK, Das SK, Wu HL, Chen Y. Computed tomography-based score model/nomogram for predicting technical and midterm outcomes in transjugular intrahepatic portosystemic shunt treatment for symptomatic portal cavernoma. World J Clin Cases 2020; 8:887-899. [PMID: 32190625 PMCID: PMC7062625 DOI: 10.12998/wjcc.v8.i5.887] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/19/2020] [Accepted: 02/11/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) may be technically difficult in patients with cavernous transformation of the portal vein (CTPV). Computed tomography (CT) is widely used for assessing the situation of the portal vein and its tributaries before TIPS, and an ultrasound-based Yerdel grading system has been developed, which is deemed useful for liver transplantation. Therefore, we hypothesized that a CT-based CTPV scoring system could be useful for predicting technical and midterm outcomes in TIPS treatment for symptomatic portal cavernoma.
AIM To investigate the clinical significance of a CT-based score model/nomogram for predicting technical success and midterm outcome in TIPS treatment for symptomatic CTPV.
METHODS Patients with symptomatic CTPV who had undergone TIPS from January 2010 to June 2017 were retrospectively analysed. The CTPV was graded with a score of 1-4 based on contrast-CT imaging findings of the diseased vessel. Outcome measures were technical success rate, stent patency rate, and midterm survival. Cohen’s kappa statistic, the Kaplan-Meier and log-rank tests, and uni- and multivariable analyses were performed. A nomogram was constructed and verified by calibration and decision curve analysis.
RESULTS A total of 76 patients (45 men and 31 women; mean age, 52.3 ± 14.7 years) were enrolled in the study. The inter-reader agreement (κ) of the CTPV score was 0.81. TIPS was successfully placed in 78% of patients (59/76). The independent predictor of technical success was CTPV score (odds ratio [OR] = 5.56, 95% confidence interval [CI]: 3.55-9.67, P = 0.002). The independent predictors of primary TIPS patency were CTPV score and splenectomy (OR = 9.22, 95%CI: 4.78-13.45, P = 0.009; OR = 4.67, 95%CI: 2.59-7.44, P = 0.017). The survival rates differed significantly between the TIPS success and failure groups. The clinical nomogram was made up of patient age, model for end-stage liver disease score, and CTPV score. The calibration curves and decision curve analysis verified the usefulness of the CTPV score-based nomogram for clinical practice.
CONCLUSION TIPS should be considered a safe and feasible therapy for patients with symptomatic CTPV. Furthermore, the CT-based score model/nomogram might aid interventional radiologists in therapeutic decision-making.
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Affiliation(s)
- Xiang-Ke Niu
- Department of Radiology, Affiliated Hospital of Chengdu University, Chengdu 610081, Sichuan Province, China
| | - Sushant Kumar Das
- Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Hong-Lin Wu
- Department of Radiology, Affiliated Hospital of Chengdu University, Chengdu 610081, Sichuan Province, China
| | - Yong Chen
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
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Vizzutti F, Schepis F, Arena U, Fanelli F, Gitto S, Aspite S, Turco L, Dragoni G, Laffi G, Marra F. Transjugular intrahepatic portosystemic shunt (TIPS): current indications and strategies to improve the outcomes. Intern Emerg Med 2020; 15:37-48. [PMID: 31919780 DOI: 10.1007/s11739-019-02252-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/03/2019] [Indexed: 12/16/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) represents a very effective treatment of complications of portal hypertension. Established indications to TIPS in cirrhotic patients include portal hypertensive bleeding and refractory ascites. Over the years additional indications have been proposed, such as the treatment of vascular disease of the liver, hepatic hydrothorax, hepatorenal syndrome and bleeding from ectopic varices. Indications under evaluation include treatment of portal hypertension prior to major abdominal surgery and treatment of portal vein thrombosis. In spite of these advances, there are still uncertainties regarding the appropriate workup for patients to be scheduled for TIPS. Moreover, prevention and management of post-TIPS complications including hepatic encephalopathy and heart failure are still suboptimal. These issues are particularly relevant considering aging in TIPS candidates in Western countries. Correct selection of patients is mandatory to prevent complications which may eventually frustrate the good hemodynamic results and worsen the patient's quality of life or even life expectancy. The possible role of small diameter TIPS to prevent post-procedural complications is discussed.
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Affiliation(s)
- Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Filippo Schepis
- Department of Internal Medicine, University of Modena and Reggio, Modena, Italy
| | - Umberto Arena
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Fabrizio Fanelli
- Department of Radiology, Interventional Radiology, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Silvia Aspite
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Laura Turco
- Department of Internal Medicine, University of Modena and Reggio, Modena, Italy
| | - Gabriele Dragoni
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Giacomo Laffi
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy.
- Center for Research, High Education and Transfer DENOThe, University of Florence, Florence, Italy.
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Percutaneous portal vein recanalization using self-expandable nitinol stents in patients with non-cirrhotic non-tumoral portal vein occlusion. Diagn Interv Imaging 2019; 100:147-156. [DOI: 10.1016/j.diii.2018.07.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/26/2018] [Accepted: 07/04/2018] [Indexed: 12/16/2022]
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16
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Li LN, Sun XY, Wang GC, Tian XG, Zhang MY, Jiang KT, Zhang CQ. Transjugular intrahepatic portosystemic shunt prevents rebleeding in cirrhotic patients having cavernous transformation of the portal vein without improving their survival. J Dig Dis 2019; 20:89-96. [PMID: 30629804 DOI: 10.1111/1751-2980.12702] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 12/18/2018] [Accepted: 12/20/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To compare the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) and endoscopic variceal ligations (EVL) plus propranolol in decreasing rebleeding and improving survival rates in cirrhotic patients with cavernous transformation of the portal vein (CTPV). METHODS Cirrhotic patients with CTPV and a history of variceal bleeding who were treated for recurrent variceal bleeding between June 2010 and July 2016 were identified and classified based on the treatment they received (TIPS or EVL plus propranolol). Their characteristics and clinical data were recorded. The rebleeding and long-term survival rates between the two groups were analyzed. RESULTS A total of 51 patients were included, of whom 25 were treated with TIPS and 26 with EVL plus propranolol. The mean duration of follow up was 21 months (range 1-47 months) in the former group and 27 months (range 6-73 months) in the latter group. The recurrent variceal bleeding-free rate increased remarkably in the TIPS group compared with the EVL + propranolol group (P = 0.047). Three (14.3%) patients died in the TIPS group, and one (3.8%) in the EVL plus propranolol group (P = 0.305). Hepatic encephalopathy occurred in 14.3% (3/21) of the patients in the TIPS group and in 3.8% (1/26) in the EVL + propranolol group (P = 0.202). CONCLUSION TIPS appeared to be more effective in preventing rebleeding in cirrhotic patients with CTPV compared with EVL plus propranolol, without improving survival.
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Affiliation(s)
- Lu Ning Li
- Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong Province, China.,Department of Gastroenterology, Linyi People's Hospital, Linyi, Shandong Province, China
| | - Xiao Yan Sun
- Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong Province, China
| | - Guang Chuan Wang
- Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong Province, China
| | - Xiang Guo Tian
- Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong Province, China
| | - Ming Yan Zhang
- Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong Province, China
| | - Kai Tong Jiang
- Department of Gastroenterology, Linyi People's Hospital, Linyi, Shandong Province, China
| | - Chun Qing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong Province, China
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17
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Li ZP, Wang SS, Wang GC, Huang GJ, Cao JQ, Zhang CQ. Transjugular intrahepatic portosystemic shunt for the prevention of recurrent esophageal variceal bleeding in patients with cavernous transformation of portal vein. Hepatobiliary Pancreat Dis Int 2018; 17:517-523. [PMID: 30262421 DOI: 10.1016/j.hbpd.2018.09.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 08/22/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treatment options for patients with cavernous transformation of portal vein (CTPV) are limited. This study aimed to evaluate the feasibility, efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) to prevent recurrent esophageal variceal bleeding in patients with CTPV. METHODS We retrospectively analyzed 67 consecutive patients undergone TIPS from January 2011 to December 2016. All patients were diagnosed with CTPV. The indication for TIPS was a previous episode of variceal bleeding. The data on recurrent bleeding, stent patency, hepatic encephalopathy and survival were retrieved and analyzed. RESULTS TIPS procedure was successfully performed in 56 out of 67 (83.6%) patients with CTPV. TIPS was performed via a transjugular approach alone (n = 15), a combined transjugular/transhepatic approach (n = 33) and a combined transjugular/transsplenic approach (n = 8). Mean portosystemic pressure gradient (PSG) decreased from 28.09 ± 7.28 mmHg to 17.53 ± 6.12 mmHg after TIPS (P < 0.01). The probability of the remaining free recurrent variceal bleeding was 87.0%. The probability of TIPS patency reached 81.5%. Hepatic encephalopathy occurrence was 27.8%, and survival rate was 88.9% until the end of follow-up. Four out of 11 patients who failed TIPS died, and 4 had recurrent bleeding. CONCLUSIONS TIPS should be considered a safe and feasible alternative therapy to prevent recurrent esophageal variceal bleeding in patients with CTPV, and to achieve clinical improvement.
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Affiliation(s)
- Zhao-Peng Li
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China; Department of Interventional Radiology, Jining No.1 People(')s Hospital, Jining 272011, China
| | - Sui-Sui Wang
- Department of Pediatrics, The Affiliated Hospital of Jining Medical College, Jining 272000, China
| | - Guang-Chuan Wang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
| | - Guang-Jun Huang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
| | - Jing-Qin Cao
- Department of Interventional Radiology, Jining No.1 People(')s Hospital, Jining 272011, China
| | - Chun-Qing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China.
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18
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The role of transjugular intrahepatic portosystemic shunt in the management of portal vein thrombosis: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2018; 30:1187-1193. [PMID: 30074506 DOI: 10.1097/meg.0000000000001219] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal vein thrombosis (PVT) remains controversial. This study aimed to conduct a systematic review and meta-analysis to evaluate the role of TIPS for the management of PVT in adult patients with liver disease. PATIENTS AND METHODS Multiple databases were searched through April 2017. Data were gathered to estimate the rates of technical success, portal vein recanalization, portal patency, hepatic encephalopathy, and mean change in portal pressure gradient in patients with PVT who underwent TIPS. Estimates were pooled across studies using the random effects model. RESULTS Eighteen studies were included in the analysis. The pooled technical success rate was 86.7% [95% confidence interval (CI)=78.6-92.1%]. Rate of portal vein recanalization was 84.4% (95% CI=78.4-89.0%). The rate of complete recanalization was 73.7% (95% CI=64.3-81.3%). Portal patency was 86.9% (95% CI=79.7-91.8%). Mean change in portal pressure gradient was 14.5 mmHg (95% CI=11.3-17.7 mmHg). Hepatic encephalopathy was 25.3% (95% CI=19.2-32.6%). The number of major adverse events reported across studies was low. The majority of the analyses were not associated with substantial heterogeneity. CONCLUSION The use of TIPS in the management of PVT is feasible and effective in achieving a significant and sustainable reduction in clot burden with a low risk of major complications. TIPS should be considered as a viable treatment option in patients with PVT. Given the limited amount of randomized comparative studies reported, additional trials are warranted to assess the safety and efficacy of TIPS as a treatment modality in PVT, in comparison to other treatment options, such as anticoagulation.
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19
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Bodini FC, Rossi S, Veronese L, Colombi D, Michieletti E. Extrahepatic Portosystemic Shunt via the Coronary Vein in Noncirrhotic Chronic Portal Vein Thrombosis. J Vasc Interv Radiol 2018; 29:1327-1330. [PMID: 30146217 DOI: 10.1016/j.jvir.2018.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 03/07/2018] [Accepted: 03/11/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Flavio Cesare Bodini
- Department of Radiology, Radiology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Sandro Rossi
- III Medical Clinic, Department of Internal Medicine, IRCCS - Policlinico San Matteo Foundation, Pavia, Italy
| | - Letizia Veronese
- III Medical Clinic, Department of Internal Medicine, IRCCS - Policlinico San Matteo Foundation, Pavia, Italy
| | - Davide Colombi
- Department of Radiology, Radiology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Emanuele Michieletti
- Department of Radiology, Radiology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
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Transjugular intrahepatic portosystemic shunt creation for cirrhotic portal hypertension is well tolerated among patients with portal vein thrombosis. Eur J Gastroenterol Hepatol 2018; 30:668-675. [PMID: 29462027 DOI: 10.1097/meg.0000000000001097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Portal vein thrombosis (PVT) develops in cirrhotic patients because of stagnation of blood flow. Transjugular intrahepatic portosystemic shunt (TIPS) creates a low-resistance conduit that restores portal venous patency and blood flow. AIM The effect of PVT on transplant-free survival in cirrhotic patients undergoing TIPS creation was evaluated. PATIENTS AND METHODS A multicenter, retrospective cohort study of patients who underwent TIPS creation for cirrhotic portal hypertension was carried out. A Cox model with propensity score adjustment was developed to evaluate the effect of PVT on 90-day and 3-year transplant-free survival. A subgroup analysis examining mortality of those with superior and inferior PVT was also carried out. RESULTS A total of 252 consecutive TIPS creations were assessed, including 65 in patients with PVT. Survival of patients with high Model for End-stage Liver Disease scores (≥18) and PVT was not statistically different compared with patients with low Model for End-stage Liver Disease scores (<18) and no PVT at 90 days (P=0.46) and 3 years (P=0.42). Those with superior PVT had improved 90-day and 3-year survival both compared with patients with a inferior PVT and those without a PVT (P<0.01, all cases). CONCLUSION The presence of PVT does not impair the prognosis of patients following TIPS creation, particularly in patients with superior portal occlusion.
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21
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Ten-year experience of transjugular intrahepatic portosystemic shunt for noncirrhotic portal hypertension. Eur J Gastroenterol Hepatol 2018; 30:557-562. [PMID: 29324586 DOI: 10.1097/meg.0000000000001067] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is considered to be well suited for the treatment of noncirrhotic portal hypertension (NCPHT) because of a usually severe portal hypertension (PHT) and a mild liver failure, but very less data are available. PATIENTS AND METHODS Records of patients referred for TIPS between 2004 and 2015 for NCPHT were reviewed. No patient should have clinical or biological or histological features of cirrhosis. RESULTS Twenty-five patients with a wide variety of histological lesions (sinusoidal dilatations, granulomatosis, regenerative nodular hyperplasia, obliterative portal venopathy, or subnormal liver) and a wide variety of associated diseases (thrombophilia, sarcoidosis, common variable immunodeficiency, scleroderma, Castleman's disease, early primitive biliary cirrhosis, congenital liver fibrosis, chemotherapy, purinethol intake, and congenital varices) were included. Two complications occurred during the procedure: one periprosthetic hematoma and the other misposition of a covered stent. During the first month, two other patients had an early thrombosis, another had induced encephalopathy, and one died of early rebleeding. Two of these complications occurred in patients with cavernoma. With a mean follow-up of 39 months, 10 patients experienced at least one episode of spontaneous encephalopathy, with three of these patients requiring a stent reduction. Five patients had a recurrence of their initial symptoms, and one had an asymptomatic hemodynamic dysfunction. CONCLUSION TIPS is effective in NCPHT but can be technically difficult, especially in the case of cavernoma. Good liver function does not prevent the occurrence of long-term encephalopathy.
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Yue-Meng W, Li YH, Wu HM, Yang J, Yang LH, Xu Y. Portal Vein Thrombosis in Patients With Cirrhosis Undergoing Elective Transjugular Intrahepatic Portosystemic Shunt: Risk Factors, Warfarin Efficacy, and Clinical Outcomes. Clin Appl Thromb Hemost 2018; 24:462-470. [PMID: 28110540 PMCID: PMC6714657 DOI: 10.1177/1076029616689593] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Portal vein thrombosis (PVT) is a common complication in cirrhosis. The aim of this study was to determine risk factors for PVT, assess the efficacy of anticoagulant therapy, and evaluate the effects of PVT on patients with cirrhosis undergoing elective transjugular intrahepatic portosystemic shunt (TIPSS). A total of 101 patients with cirrhosis undergoing elective TIPSS were prospectively studied. After TIPSS, all patients received preventive therapy for PVT and were followed up at 3, 6, 12, and 24 months. Clinical outcomes were compared between patients who developed PVT after TIPSS and those who did not. Multivariate analysis showed that white blood cell count (relative risk [RR]: 0.377; 95% confidence interval [CI]: 0.132-0.579; P = .001), Child-Turcotte-Pugh score (RR: 1.547; 95% CI: 1.029-2.365; P = .032), and ascites (RR: 1.264; 95% CI: 1.019-1.742; P = .040) were independent predictors for PVT. Warfarin treatment within 12 months achieved significantly higher rates of complete recanalization than aspirin or clopidogrel in patients with PVT (54.5% vs 31.3%; P = .013), although adverse events were similar between the 2 groups ( P > .05). Patients without PVT had significantly lower 2-year cumulative rates of variceal rebleeding (15.9% vs 36.6%; P = .023), shunt dysfunction (27.0% vs 46.8%; P = .039), hepatic encephalopathy (24.1% vs 42.6%; P = .045), and hepatocellular carcinoma (11.4% vs 31.2%; P = .024) and markedly higher 2-year cumulative survival rates (89.8% vs 72.9%; P = .041) than those with PVT. The PVT is associated with poorer clinical outcomes in TIPSS-treated patients, and warfarin is both safe and more effective in recanalizing PVT than aspirin or clopidogrel.
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Affiliation(s)
- Wan Yue-Meng
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University, Kunming City, Yunnan Province, China
- Graduate Department of Kunming Medical University, Kunming city, Yunnan province, China
| | - Yu-Hua Li
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University, Kunming City, Yunnan Province, China
| | - Hua-Mei Wu
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University, Kunming City, Yunnan Province, China
| | - Jing Yang
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University, Kunming City, Yunnan Province, China
| | - Li-Hong Yang
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University, Kunming City, Yunnan Province, China
| | - Ying Xu
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University, Kunming City, Yunnan Province, China
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Mantaka A, Augoustaki A, Kouroumalis EA, Samonakis DN. Portal vein thrombosis in cirrhosis: diagnosis, natural history, and therapeutic challenges. Ann Gastroenterol 2018; 31:315-329. [PMID: 29720857 PMCID: PMC5924854 DOI: 10.20524/aog.2018.0245] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/26/2017] [Indexed: 12/13/2022] Open
Abstract
Portal vein thrombosis (PVT) is a frequent complication in cirrhosis and its prevalence increases with disease severity. Several factors are involved in the development and progression of PVT. The challenge for the management of PVT is the precise evaluation of the bleeding risk as opposed to life-threatening extension of thrombosis. Nevertheless, the impact on the progression and outcome of liver disease is unclear. A critical evaluation of the available data discloses that treating PVT in cirrhotics is safe and effective. However, there are open issues, such as which anticoagulant could represent a safer therapeutic option, and when and for how long this treatment should be administered to cirrhotic patients with PVT.
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Affiliation(s)
- Aikaterini Mantaka
- Department of Gastroenterology and Hepatology, University Hospital of Crete, Heraklion, Crete, Greece
| | - Aikaterini Augoustaki
- Department of Gastroenterology and Hepatology, University Hospital of Crete, Heraklion, Crete, Greece
| | - Elias A Kouroumalis
- Department of Gastroenterology and Hepatology, University Hospital of Crete, Heraklion, Crete, Greece
| | - Dimitrios N Samonakis
- Department of Gastroenterology and Hepatology, University Hospital of Crete, Heraklion, Crete, Greece
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Rössle M, Schultheiss M. Timing of the Treatment of Portal Vein Thrombosis in Patients with Cirrhosis: A German Hepatologist's Perspective. J Transl Int Med 2018; 6:11-15. [PMID: 29607298 PMCID: PMC5874481 DOI: 10.2478/jtim-2018-0003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Martin Rössle
- University Hospital, Department of Gastroenterology and Hepatology, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Michael Schultheiss
- University Hospital, Department of Gastroenterology and Hepatology, Hugstetterstrasse 55, 79106, Freiburg, Germany
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Torres-Machorro A, Guerrero-Hernandez M, Anaya-Ayala JE, Torre A, Laparra-Escareno H, Cuen-Ojeda C, Garcia-Alva R, Hinojosa CA. Analysis of the MELD Score Impact in the Outcome of Endovascular Portal Vein Reconstruction. Ann Hepatol 2017; 16:950-958. [PMID: 29055930 DOI: 10.5604/01.3001.0010.5287] [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
INTRODUCTION Endovascular therapy represents a less invasive alternative to open surgery for reconstruction of the portal vein (PV) and the spleno-mesenteric venous confluence to treat Portal hypertension. The objective of this study is to determine if the Model for End-Stage Liver Disease (MELD) score is a useful method to evaluate the risk of morbidity and mortality during endovascular approaches. MATERIAL AND METHODS Patients that underwent endovascular reconstruction of the PV or spleno-mesenteric confluence were identified retrospectively. Data were collected from November 2011 to August 2016. The MELD score was calculated using international normalized ratio, serum billirubin and creatinine. Patients were grouped into moderate (≤ 15) and high (> 15) MELD. Associations of the MELD score on the postprocedural morbidity, mortality and vessels patency were assessed by two-sided Fisher's exact test. RESULTS Seventeen patients were identified; MELD score distribution was: ≤ 15 in 10 patients (59%) and > 15 in 7 (41%). Even distribution of severe PV thrombosis was treated in both groups, performing predominately jugular access in the high MELD score group (OR 0.10; 95%; CI 0.014-0.89; p = 0.052) in contrast to a percutaneous transhepatic access in the moderate MELD score group. Analysis comparing moderate and high MELD scores was not able to demonstrate differences in mortality, morbidity or patency rates. CONCLUSION MELD score did not prove to be a useful method to evaluate risk of morbidity and mortality; however a high score should not contraindicate endovascular approaches. In our experience a high technical success, good patency rates and low complication rates were observed.
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Affiliation(s)
- Adriana Torres-Machorro
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy. Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán". Mexico City, Mexico
| | - Manuel Guerrero-Hernandez
- Department of Radiology, Section of Interventional Radiology. Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán". Mexico City, Mexico
| | - Javier E Anaya-Ayala
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy. Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán". Mexico City, Mexico
| | - Aldo Torre
- Department of Gastroenterology, Section of Hepatology. Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán". Mexico City, Mexico
| | - Hugo Laparra-Escareno
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy. Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán". Mexico City, Mexico
| | - Cesar Cuen-Ojeda
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy. Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán". Mexico City, Mexico
| | - Ramón Garcia-Alva
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy. Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán". Mexico City, Mexico
| | - Carlos A Hinojosa
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy. Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán". Mexico City, Mexico
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Wan YM, Li YH, Wu HM, Xu ZY, Xu Y, Yang LH, Wu XN, Yang JH. Portal vein thrombosis before and after transjugular intrahepatic portosystemic shunt placement: An observational study (STROBE compliant). Medicine (Baltimore) 2017; 96:e8498. [PMID: 29137043 PMCID: PMC5690736 DOI: 10.1097/md.0000000000008498] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Portal vein thrombosis (PVT) is common in patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt (TIPS). This study had 3-fold aims: to assess risk factors for PVT; to determine the efficacy of anticoagulant therapy; to investigate the impact of PVT on clinical outcomes in TIPS-treated cirrhosis.Between June 2012 and February 2016, 126 TIPS-treated patients with cirrhosis were enrolled and studied prospectively. Enrolled patients were screened for PVT before TIPS and at 3, 6, 12, and 24 months post-TIPS. All patients received warfarin (1.5-3.0 mg/day) or aspirin (100 mg/day) or clopidogrel (75 mg/day) post-TIPS. Results of patients with and without PVT (baseline and de novo) were compared.White blood cell (WBC) counts (odds ratio (OR): 0.430, 95% confidence interval (CI): 0.251-0.739, P = .002) and Child-Turcotte-Pugh (CTP) score (OR: 2.377, 95% CI: 1.045-5.409, P = .039) were significant baseline predictors for PVT in TIPS-treated patients with cirrhosis. Warfarin resulted in markedly greater rates of complete recanalization than aspirin or clopidogrel (P < .05) in patients with PVT. Patients with PVT had markedly higher 2-year cumulative rates of variceal rebleeding, shunt dysfunction, hepatic encephalopathy, and hepatocellular carcinoma, and prominently lower overall survival than those without PVT (P < .05).In TIPS-treated patients with cirrhosis, lower WBC count and higher CTP score were independent baseline predictors for PVT; patients with PVT had worse clinical outcomes than those without; warfarin may be more effective in recanalizing PVT than aspirin or clopidogrel.
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Affiliation(s)
- Yue-Meng Wan
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University
- Public Health Institute of Kunming Medical University, Kunming City, Yunnan Province, China
| | - Yu-Hua Li
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University
| | - Hua-Mei Wu
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University
| | - Zhi-Yuan Xu
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University
| | - Ying Xu
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University
| | - Li-Hong Yang
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University
| | - Xi-Nan Wu
- Public Health Institute of Kunming Medical University, Kunming City, Yunnan Province, China
| | - Jin-Hui Yang
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University
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Martín-Llahí M, Albillos A, Bañares R, Berzigotti A, García-Criado MÁ, Genescà J, Hernández-Gea V, Llop-Herrera E, Masnou-Ridaura H, Mateo J, Navascués CA, Puente Á, Romero-Gutiérrez M, Simón-Talero M, Téllez L, Turon F, Villanueva C, Zarrabeitia R, García-Pagán JC. Enfermedades vasculares del hígado. Guías Clínicas de la Sociedad Catalana de Digestología y de la Asociación Española para el Estudio del Hígado. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 40:538-580. [DOI: 10.1016/j.gastrohep.2017.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 03/29/2017] [Indexed: 12/11/2022]
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Techniques and long-term effects of transjugular intrahepatic portosystemic shunt on liver cirrhosis-related thrombotic total occlusion of main portal vein. Sci Rep 2017; 7:10868. [PMID: 28883536 PMCID: PMC5589901 DOI: 10.1038/s41598-017-11455-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 08/23/2017] [Indexed: 02/07/2023] Open
Abstract
Portal vein hypertension (PVH) in liver cirrhosis complicated with portal venous thrombosis (PVT) has been mainly treated with transjugular intrahepatic portosystemic shunt (TIPS). The clinical effects of TIPS have been confirmed, however, no large-scale studies have been focused on technical analyses and a long-term follow-up, especially on thrombotic total occlusion of main portal vein (MPV). To demonstrate critical techniques and clinical outcome of TIPS on liver cirrhosis-related thrombotic total occlusion of MPV, 98 patients diagnosed with liver cirrhosis related thrombotic total occlusion of MPV and treated with TIPS from January 2000 to January 2010 were retrospectively analyzed. Twenty-three (23.5%) patients had MPV (single site) thrombosis, 55 (56.1%) had multiple site-thrombosis (MPV and other), 17 (17.3%) had cavernous transformation of portal vein, and 3 (3.1%) had post-transplant thrombosis. The successful rate of TIPS was 90.7%, without any procedure-related deaths or severe complications. Mean portal pressure was dropped from 33.08 ± 1.38 mmHg preoperatively to 20.18 ± 0.83 mmHg postoperatively (p < 0.001). Collectively, TIPS is safe and effective in treating liver cirrhosis-related thrombotic total occlusion of MPV. This complex procedure requires combination of indirect portography and percutaneous transhepatic portal techniques to increase the rate of success.
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Lv Y, He C, Wang Z, Guo W, Wang J, Bai W, Zhang L, Wang Q, Liu H, Luo B, Niu J, Li K, Tie J, Yin Z, Fan D, Han G. Association of Nonmalignant Portal Vein Thrombosis and Outcomes after Transjugular Intrahepatic Portosystemic Shunt in Patients with Cirrhosis. Radiology 2017; 285:999-1010. [PMID: 28682164 DOI: 10.1148/radiol.2017162266] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose To assess the effects of preexisting nonmalignant portal vein thrombosis (PVT) on mortality, clinical relapse, shunt dysfunction, and overt hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) placement. Materials and Methods This retrospective study was approved by the institutional ethics committee, and written informed consent was obtained from all patients. From March 2001 to December 2014, 1171 consecutive patients with cirrhosis (762 men, 409 women; mean age, 50.0 years ± 12.8) and PVT (n = 212; 18%) or without PVT (n = 959; 82%) who underwent TIPS placement were included. The association between PVT and outcomes after TIPS placement was measured by using Fine and Gray competing risk regression model after adjusting for important baseline characteristics or by using propensity score. The Wald test was used to assess the homogeneity of the effects of PVT across different strata (stratified PVT according to the stages, degrees, and extents) and major subgroups. Results During a median follow-up period of 28.4 months, 507 (43%) patients died, 373 (32%) experienced clinical relapse, 217 (19%) developed shunt dysfunction, and 475 (41%) experienced overt HE. Compared with patients without PVT, patients with PVT had a similar risk of mortality (adjusted hazard ratio, 0.82; 95% confidence interval [CI]: 0.63, 1.09; P = .17), clinical relapse (adjusted hazard ratio, 1.24; 95% CI: 0.92, 1.69; P = .15), shunt dysfunction (adjusted hazard ratio, 1.03; 95% CI: 0.70, 1.51; P = .43), and overt HE (adjusted hazard ratio, 0.88; 95% CI: 0.70, 1.11; P = .29). Furthermore, the effects of PVT were consistent across the relevant strata and subgroups. Conclusion There was no evidence that preexisting PVT was associated with an improved or worsened outcome after TIPS. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Yong Lv
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Chuangye He
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Zhengyu Wang
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Wengang Guo
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Jianhong Wang
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Wei Bai
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Lei Zhang
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Qiuhe Wang
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Haibo Liu
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Bohan Luo
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Jing Niu
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Kai Li
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Jun Tie
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Zhanxin Yin
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Daiming Fan
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
| | - Guohong Han
- From the Department of Liver Diseases and Digestive Interventional Radiology (Y.L., C.H., Z.W., W.G., W.B., L.Z., Q.W., H.L., B.L., J.N., K.L., J.T., Z.Y., G.H.), Department of Ultrasound (J.W.), and State Key Laboratory of Cancer Biology (D.F.), National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, No. 127 Changle West Road, Xi'an 710032, China
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Fagiuoli S, Bruno R, Debernardi Venon W, Schepis F, Vizzutti F, Toniutto P, Senzolo M, Caraceni P, Salerno F, Angeli P, Cioni R, Vitale A, Grosso M, De Gasperi A, D'Amico G, Marzano A. Consensus conference on TIPS management: Techniques, indications, contraindications. Dig Liver Dis 2017; 49:121-137. [PMID: 27884494 DOI: 10.1016/j.dld.2016.10.011] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/27/2016] [Accepted: 10/17/2016] [Indexed: 12/11/2022]
Abstract
The trans jugular intrahepatic Porto systemic shunt (TIPS) is no longer viewed as a salvage therapy or a bridge to liver transplantation and is currently indicated for a number of conditions related to portal hypertension with positive results in survival. Moreover, the availability of self-expandable polytetrafluoroethylene (PTFE)-covered endoprostheses has dramatically improved the long-term patency of TIPS. However, since the last updated International guidelines have been published (year 2009) new evidence have come, which have open the field to new indications and solved areas of uncertainty. On this basis, the Italian Association of the Study of the Liver (AISF), the Italian College of Interventional Radiology-Italian Society of Medical Radiology (ICIR-SIRM), and the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI) promoted a Consensus Conference on TIPS. Under the auspices of the three scientific societies, the consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Bergamo on June 4th and 5th, 2015. The final statements presented here were graded according to quality of evidence and strength of recommendations and were approved by an independent jury. By highlighting strengths and weaknesses of current indications to TIPS, the recommendations of AISF-ICIR-SIRM-SIAARTI may represent the starting point for further studies.
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Affiliation(s)
- Stefano Fagiuoli
- Gastroenterologia Epatologia e Trapiantologia, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Raffaele Bruno
- Dept. of Infectious Diseases, Hepatology Outpatients Unit, University of Pavia-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Wilma Debernardi Venon
- Gastroepatologia, AOU Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
| | - Filippo Schepis
- Department of Gastroenterology University of Modena and Reggio Emilia, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Pierluigi Toniutto
- Medical Liver Transplant Section, Department of Medical Sciences Experimental and Clinical, Internal Medicine, University of Udine, Italy
| | - Marco Senzolo
- Unità di Trapianto Multiviscerale, Gastroenterologia, Dipartimento di Scienze Chirurgiche e Gastroenterologiche, Università-Ospedale di Padova, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Francesco Salerno
- Department of Internal Medicine, Policlinico IRCCS San Donato, University of Milan, Italy
| | - Paolo Angeli
- Internal Medicine and Hepatology Department of Medicine (DIMED), University of Padova, Italy
| | - Roberto Cioni
- Dipartimento di Radiologia Diagnostica e Interventistica, UO di Radiologia Interventistica, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Alessandro Vitale
- U.O.C. di Chirurgia Epatobiliare e del Trapianto Epatico, Azienda Ospedaliera Università di Padova, Italy
| | - Maurizio Grosso
- Department of Radiology S. Croce and Carle Hospital Cuneo, Italy
| | - Andrea De Gasperi
- 2° Servizio Anestesia e Rianimazione-Ospedale Niguarda Ca Granda, Milan, Italy
| | | | - Alfredo Marzano
- Gastroepatologia, AOU Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
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Qi X, Guo X. An early decision of transjugular intrahepatic portosystemic shunt may be considered for non-malignant and non-cirrhotic portal vein thrombosis with ascites: a concise review of the theoretical possibility and practical difficulty. Arch Med Sci 2016; 12:1381-1383. [PMID: 27904533 PMCID: PMC5108399 DOI: 10.5114/aoms.2016.62921] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 01/16/2015] [Indexed: 02/07/2023] Open
Affiliation(s)
- Xingshun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
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Dell’Era A, Seijo S. Portal vein thrombosis in cirrhotic and non cirrhotic patients: from diagnosis to treatment. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1215907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Alessandra Dell’Era
- Dipartimento di Scienze Biomediche e Cliniche ‘L. Sacco’, Università degli Studi di Milano, UOC Gastroenterologia - ASST Fatebenefratelli Sacco - Ospedale ‘Luigi Sacco’ Polo Universitario, Milan, Italy
| | - Susana Seijo
- CTO, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Abstract
BACKGROUND Portal vein thrombosis (PVT) is a complication of cirrhosis. However, whether PVT worsens cirrhosis outcome is a debated issue. AIM To report an update on the management of PVT. METHODS A review was performed on the outcome, prevention, and treatment of PVT. RESULTS Some studies suggest that PVT could worsen the rate of hepatic decompensation and survival of cirrhosis, whereas others report a non-negative impact of PVT in the outcome of cirrhosis. Therefore, the prognostic value of PVT in cirrhosis remains a gray zone. One single randomized-controlled trial reported that enoxaparin could prevent PVT, delay the occurrence of hepatic decompensation, and improve survival. However, no further study data confirmed this assumption and the issue is not actually generalizable. Numerous studies report that anticoagulation determines a relatively high rate of portal vein recanalization in cirrhotics PVT. However, further data are warranted to confirm the risk-to-benefit of anticoagulation, especially bleeding. Transjugular intrahepatic portosystemic shunt (TIPS) has been reported to be effective as a treatment of PVT in cirrhosis, with the advantage of avoiding the risk of bleeding linked to anticoagulation. However, there are no data comparing TIPS with anticoagulation as a treatment of PVT in cirrhosis. Furthermore, there is no evidence on whether both anticoagulation and TIPS improve survival. CONCLUSION It is uncertain whether PVT affects cirrhosis outcome. Further data are needed to weigh the risk/benefit ratio of enoxaparin for the prevention of PVT in cirrhosis. Anticoagulation or TIPS should probably be indicated in liver transplantation candidates, but avoided in patients not suitable for liver transplantation and with an otherwise poor prognosis. Future studies should evaluate which subgroup of cirrhotics with PVT may benefit from treatment. Management of PVT in cirrhosis should be personalized.
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Madoff DC, Gaba RC, Weber CN, Clark TWI, Saad WE. Portal Venous Interventions: State of the Art. Radiology 2016; 278:333-53. [PMID: 26789601 DOI: 10.1148/radiol.2015141858] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In recent decades, there have been numerous advances in the management of liver cancer, cirrhosis, and diabetes mellitus. Although these diseases are wide ranging in their clinical manifestations, each can potentially be treated by exploiting the blood flow dynamics within the portal venous system, and in some cases, adding cellular therapies. To aid in the management of these disease states, minimally invasive transcatheter portal venous interventions have been developed to improve the safety of major hepatic resection, to reduce the untoward effects of sequelae from end-stage liver disease, and to minimize the requirement of exogenously administered insulin for patients with diabetes mellitus. This state of the art review therefore provides an overview of the most recent data and strategies for utilization of preoperative portal vein embolization, transjugular intrahepatic portosystemic shunt placement, balloon retrograde transvenous obliteration, and islet cell transplantation.
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Affiliation(s)
- David C Madoff
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
| | - Ron C Gaba
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
| | - Charles N Weber
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
| | - Timothy W I Clark
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
| | - Wael E Saad
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
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Qi X, He C, Guo W, Yin Z, Wang J, Wang Z, Niu J, Bai M, Yang Z, Fan D, Han G. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with variceal bleeding in liver cirrhosis: outcomes and predictors in a prospective cohort study. Liver Int 2016; 36:667-76. [PMID: 26235541 DOI: 10.1111/liv.12929] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 07/21/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND & AIMS The role of transjugular intrahepatic portosystemic shunt (TIPS) for the secondary prophylaxis of variceal bleeding in cirrhotic patients with portal vein thrombosis (PVT) remains obscure. This prospective cohort study aimed to assess the risk factors associated with TIPS technical success, outcome and prognosis in cirrhotic patients with PVT and a history of variceal bleeding. METHODS Between May 2009 and April 2011, 51 cirrhotic patients with PVT who attempted TIPS procedures for the prevention of variceal rebleeding were enrolled. RESULTS TIPS success rate was 84% (43/51). An increased degree of thrombosis within the portal trunk and portal vein branches was inversely associated with TIPS success. Median follow-up time was 40.07 months (range: 0.02-56.87). The cumulative risk of rebleeding was significantly different between TIPS success and failure group (P = 0.002). The univariate analysis also demonstrated that TIPS failure was the only significant predictor associated with rebleeding (hazard ratio [HR] = 4.174, 95% confidence interval [CI]: 1.558-11.186). In TIPS success group, the cumulative rates free of shunt dysfunction at the 6th and 12th month were 79% and 76% respectively. Absence of total superior mesenteric vein (SMV) thrombosis was the only independent predictor (HR = 0.189, 95% CI: 0.047-0.755). In TIPS success group, the 1- and 3-year cumulative survival rates were 77% and 62% respectively. Albumin level was the only independent predictor (HR = 0.877, 95% CI: 0.779-0.986). CONCLUSION Successful TIPS insertions could effectively prevent from rebleeding in cirrhotic patients with PVT and variceal bleeding. Degree of PVT and SMV thrombosis was associated with TIPS failure and shunt dysfunction respectively.
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Affiliation(s)
- Xingshun Qi
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Chuangye He
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jianhong Wang
- Department of Ultrasound, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jing Niu
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Ming Bai
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhiping Yang
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Pretransplant Portal Vein Recanalization-Transjugular Intrahepatic Portosystemic Shunt in Patients With Complete Obliterative Portal Vein Thrombosis. Transplantation 2016; 99:2347-55. [PMID: 25905983 DOI: 10.1097/tp.0000000000000729] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic, obliterative portal vein (PV) thrombosis (PVT) represents a relative contraindication to liver transplantation (LT) in some centers. When PV thromboembolectomy is not feasible, alternative techniques (portacaval hemitransposition, portal arterialization, multivisceral transplantation) are associated with suboptimal outcomes. In cases where a chronically thrombosed PV has become obliterated, we developed PV recanalization (PVR)-transjugular intrahepatic portosystemic shunt (TIPS) to potentiate LT. We evaluated the impact of PVR-TIPS on liver function, transplant eligibility, and long-term outcomes after LT. METHODS Forty-four patients with chronic obliterative main PVT were identified during our institutional LT selection committee. After joint imaging review by transplant surgery/radiology, these patients underwent PVR-TIPS to potentiate transplant eligibility. Patients were followed by hepatology/transplant until LT, and ultimately in posttransplant clinic. The TIPS venography and serial ultrasound/MRI were used subsequently to document PV patency. RESULTS The main PV (MPV) was completely thrombosed in 17 of 44 (39%) patients; near complete (>95%) occlusion was noted in 27 of 44 (61%) patients. Direct transhepatic and transsplenic punctures were required in 11 of 43 (26%) and 3 of 43 (7%) cases, respectively. Technical success was 43 of 44 (98%) cases. At PVR-TIPS completion, persistence of MPV thrombus was noted in 33 of 43 (77%) cases. One-month TIPS venography demonstrated complete resolution of MPV thrombosis in 22 of 29 (76%) without anticoagulation. Thirty-six patients were listed for transplantation; 18 (50%) have been transplanted. Eighty-nine percent MPV patency rate and 82% survival were achieved at 5 years. CONCLUSIONS The PVR-TIPS may be considered for patients with obliterative PVT who are otherwise appropriate candidates for LT. The high rate of MPV patency post-TIPS placement suggests flow reestablishment as the dominant mechanism of thrombus resolution.
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Abstract
Transjugular intrahepatic portosystemic shunt 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 including covered stents have led to improved TIPS outcomes that have encouraged an expanded application. Evidence for other less frequent indications continues to accumulate, including the indications of primary prophylaxis in patients with high-risk acute variceal bleeding, gastric and ectopic variceal bleeding, primary treatment of medically refractory ascites, recurrent refractory ascites following liver transplantation, hepatic hydrothorax, hepatorenal syndrome, Budd-Chiari syndrome, and portal vein thrombosis. Treatment of patients with high-risk acute variceal bleeding with early TIPS and using transjugular intrahepatic portosystemic shunts as a primary therapy rather than large volume paracentesis for refractory ascites would likely be the 2 circumstances that permit expansion in the frequency of TIPS procedures. The remaining populations discussed above are relatively rare.
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Affiliation(s)
- Mitchell Smith
- Division of Interventional Radiology, University of Colorado School of Medicine, Aurora, CO
| | - Janette Durham
- Division of Interventional Radiology, University of Colorado School of Medicine, Aurora, CO.
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EASL Clinical Practice Guidelines: Vascular diseases of the liver. J Hepatol 2016; 64:179-202. [PMID: 26516032 DOI: 10.1016/j.jhep.2015.07.040] [Citation(s) in RCA: 451] [Impact Index Per Article: 56.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 07/20/2015] [Indexed: 12/11/2022]
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40
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Jeong SY, Park AW, Wilkins L. Transjugular intrahepatic portosystemic shunt using transsplenic access with balloon-assisted puncture technique in a patient with chronic and complete occlusion of portal vein. GASTROINTESTINAL INTERVENTION 2015. [DOI: 10.18528/gii150028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Qi X, Su C, Ren W, Yang M, Jia J, Dai J, Xu W, Guo X. Association between portal vein thrombosis and risk of bleeding in liver cirrhosis: A systematic review of the literature. Clin Res Hepatol Gastroenterol 2015; 39:683-91. [PMID: 25956490 DOI: 10.1016/j.clinre.2015.02.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 01/29/2015] [Accepted: 02/21/2015] [Indexed: 02/07/2023]
Abstract
AIMS A systematic review of the literature was conducted to explore the association of portal vein thrombosis (PVT) with the risk of bleeding in liver cirrhosis. METHODS PubMed, EMBASE, and Cochrane library databases were searched for all relevant papers, which compared the prevalence of bleeding at baseline and/or incidence of bleeding during follow-up between cirrhotic patients with and without PVT. RESULTS Eighteen papers were eligible for this systematic review. The heterogeneity among studies was marked with regards to the treatment modalities, sources of bleeding, lengths of follow-up, and ways of data expression. But most of their findings were homozygous and suggested that the cirrhotic patients with PVT were more likely to have previous histories of bleeding at their admission and to develop de novo bleeding and/or rebleeding during the short- and long-term follow-up. The association of PVT with the risk of bleeding might be weakened in the multivariate analyses. Additionally, as for the cirrhotic patients with gastric variceal bleeding treated with medical/endoscopic therapy, the association of PVT with the risk of rebleeding remained controversial in 2 studies; as for the cirrhotic patients undergoing transjugular intrahepatic portosystemic shunts for the management of variceal bleeding, a pre-existing PVT was not associated with the risk of rebleeding. CONCLUSIONS Based on a systematic review of the literature, there was a positive association between the presence of PVT and risk of bleeding in liver cirrhosis in most of clinical conditions. However, whether PVT aggravated the development of bleeding during follow-up needed to be further explored.
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Affiliation(s)
- Xingshun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China; Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China.
| | - Chunping Su
- Library of Fourth Military Medical University, Xi'an 710032, China
| | - Weirong Ren
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Digestive Diseases, Sanmenxia Central Hospital, Henan University of Science and Technology, Xiaoshan Road, Sanmenxia 472000, China
| | - Man Yang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Gastroenterology, Songgang People's Hospital, Shenzhen 518105, China
| | - Jia Jia
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Digestive Diseases, Shaanxi Provincial People's Hospital, Xi'an 710068, China
| | - Junna Dai
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China
| | - Wenda Xu
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China.
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Quality Improvement Guidelines for Transjugular Intrahepatic Portosystemic Shunts. J Vasc Interv Radiol 2015; 27:1-7. [PMID: 26614596 DOI: 10.1016/j.jvir.2015.09.018] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 09/25/2015] [Accepted: 09/25/2015] [Indexed: 12/12/2022] Open
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Rössle M, Bausch B, Klinger C. Therapy Algorithm for Portal Vein Thrombosis in Liver Cirrhosis: The Internist's Point of View. VISZERALMEDIZIN 2015; 30:401-8. [PMID: 26288607 PMCID: PMC4513837 DOI: 10.1159/000370053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Treatment of non-malignant portal vein thrombosis (PVT) in patients with cirrhosis has been neglected in the past because of the fear of bleeding complications when using anticoagulation and due to the technical difficulties associated with the implantation of the transjugular intrahepatic portosystemic shunt (TIPS). However, PVT has a negative impact on outcome and compromises liver transplantation, warranting treatment by using anticoagulation and TIPS. METHODS This review considers studies on the treatment of PVT in cirrhosis published in the last 10 years. Unfortunately, many of these studies are limited by their retrospective design and a small sample size. RESULTS Anticoagulation using low-molecular-weight heparin (LMWH) or vitamin K antagonists is effective in the treatment of patients with limited and recent PVT, resulting in a recanalization in up to 50% of the patients. TIPS (plus local measures) results in a recanalization of up to 100% and reduces the rebleeding rate considerably in patients with recent or chronic PVT. CONCLUSION Based on the presently limited knowledge, a therapy algorithm is suggested favouring the TIPS as a first-line treatment for PVT in patients with symptomatic portal hypertension. Patients with thus far asymptomatic portal hypertension may first receive anticoagulation, preferably using LMWH. If these patients have a condition where anticoagulation is not promising (complete, extended, chronic PVT) or ineffective, or if they are candidates for liver transplantation, the TIPS may be implanted without delay.
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Affiliation(s)
- Martin Rössle
- 'PraxisZentrum für Gastroenterologie und Endokrinologie' and University Hospital Freiburg, Freiburg i.Br., Germany
| | - Birke Bausch
- Department of Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, University Hospital Freiburg, Freiburg i.Br., Germany
| | - Christoph Klinger
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany
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Harding DJ, Perera MTPR, Chen F, Olliff S, Tripathi D. Portal vein thrombosis in cirrhosis: Controversies and latest developments. World J Gastroenterol 2015; 21:6769-84. [PMID: 26078553 PMCID: PMC4462717 DOI: 10.3748/wjg.v21.i22.6769] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 03/12/2015] [Accepted: 05/07/2015] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) is encountered in liver cirrhosis, particularly in advanced disease. It has been a feared complication of cirrhosis, attributed to significant worsening of liver disease, poorer clinical outcomes and potential inoperability at liver transplantation; also catastrophic events such as acute intestinal ischaemia. Optimal management of PVT has not yet been addressed in any consensus publication. We review current literature on PVT in cirrhosis; its prevalence, pathophysiology, diagnosis, impact on the natural history of cirrhosis and liver transplantation, and management. Studies were identified by a search strategy using MEDLINE and Google Scholar. The incidence of PVT increases with increasing severity of liver disease: less than 1% in well-compensated cirrhosis, 7.4%-16% in advanced cirrhosis. Prevalence in patients undergoing liver transplantation is 5%-16%. PVT frequently regresses instead of uniform thrombus progression. PVT is not associated with increased risk of mortality. Optimal management has not been addressed in any consensus publication. We propose areas for future research to address unresolved clinical questions.
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Luo X, Wang Z, Tsauo J, Zhou B, Zhang H, Li X. Advanced Cirrhosis Combined with Portal Vein Thrombosis: A Randomized Trial of TIPS versus Endoscopic Band Ligation Plus Propranolol for the Prevention of Recurrent Esophageal Variceal Bleeding. Radiology 2015; 276:286-93. [PMID: 25759969 DOI: 10.1148/radiol.15141252] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To compare transjugular intrahepatic portosystemic shunt (TIPS) placement with or without variceal embolization with endoscopic band ligation (EBL) plus propranolol in preventing recurrent esophageal variceal bleeding in patients with advanced cirrhosis and portal vein thrombosis. MATERIALS AND METHODS The present randomized controlled trial was approved by the ethics committee board of West China Hospital. Written informed consent was obtained from each patient. Between January 2010 and December 2012, 73 patients were randomly allocated to receive TIPS (n = 37) or EBL plus propranolol (n = 36). The comparisons of recurrent variceal bleeding, hepatic encephalopathy, and survival rates were based on the Kaplan-Meier method and were compared using the log-rank test. RESULTS The mean follow-up time was 22.8 months ± 7.7(standard deviation) in the TIPS group and 20.9 months ± 8.9 in the EBL group. The 2-year probability of remaining free of recurrent variceal bleeding was higher in the TIPS group (77.8%) than in the EBL group (42.9%) (P = .002). Overall recanalization was achieved in 24 (64.9%) patients from the TIPS group and seven (19.4%) patients from the EBL group. The hepatic encephalopathy rates exhibited no significant differences between the two groups (P = .53). The 1- and 2-year probability of survival was 86.5% and 72.9%, respectively, in the TIPS group and 83.3% and 57.2%, respectively, in the EBL group, with no significant difference (P = .23). CONCLUSION TIPS was more effective than EBL plus propranolol in preventing recurrent esophageal variceal bleeding in patients with advanced cirrhosis and portal vein thrombosis and did not increase the incidence of hepatic encephalopathy. Survival was similar in both groups.
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Affiliation(s)
- Xuefeng Luo
- From the Center of Interventional Radiology and Department of Gastroenterology, West China Hospital, Sichuan University, 37 Guoxue Lane, 610041 Chengdu, Sichuan, China
| | - Zhu Wang
- From the Center of Interventional Radiology and Department of Gastroenterology, West China Hospital, Sichuan University, 37 Guoxue Lane, 610041 Chengdu, Sichuan, China
| | - Jiaywei Tsauo
- From the Center of Interventional Radiology and Department of Gastroenterology, West China Hospital, Sichuan University, 37 Guoxue Lane, 610041 Chengdu, Sichuan, China
| | - Biao Zhou
- From the Center of Interventional Radiology and Department of Gastroenterology, West China Hospital, Sichuan University, 37 Guoxue Lane, 610041 Chengdu, Sichuan, China
| | - Hailong Zhang
- From the Center of Interventional Radiology and Department of Gastroenterology, West China Hospital, Sichuan University, 37 Guoxue Lane, 610041 Chengdu, Sichuan, China
| | - Xiao Li
- From the Center of Interventional Radiology and Department of Gastroenterology, West China Hospital, Sichuan University, 37 Guoxue Lane, 610041 Chengdu, Sichuan, China
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Peck-Radosavljevic M, Angeli P, Cordoba J, Farges O, Valla D. Managing complications in cirrhotic patients. United European Gastroenterol J 2015; 3:80-94. [PMID: 25653862 DOI: 10.1177/2050640614560452] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 10/21/2014] [Indexed: 12/13/2022] Open
Abstract
Liver cirrhosis is a serious and potentially life-threatening condition. This life-threatening condition usually arises from complications of cirrhosis. While variceal bleeding is the most acute and probably best studied, several other complications of liver cirrhosis are more insidious in their onset but nevertheless more important for the long-term management and outcome of these patients. This review summarizes the topics discussed during the UEG-EASL Hepatology postgraduate course of the United European Gastroenterology Week 2013 and discusses emergency surgical conditions in cirrhotic patients, the management of hepatic encephalopathy, ascites and hepatorenal syndrome, coagulation disorders, and liver cancer.
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Affiliation(s)
| | - Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, University of Padova, Italy
| | - Juan Cordoba
- Liver Unit, Hospital Valld'Hebron, Barcelona, Spain
| | - Oliver Farges
- Department of HPB surgery HôpitalBeaujon, AP-HP, Université Paris-Diderot, Clichy-la-Garenne, France
| | - Dominique Valla
- Service d'Hépatologie, HôpitalBeaujon, AP-HP, Université Paris-Diderot, Clichy-la-Garenne, France
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Pinter SZ, Rubin JM, Kripfgans OD, Novelli PM, Vargas-Vila M, Hall AL, Fowlkes JB. Volumetric blood flow in transjugular intrahepatic portosystemic shunt revision using 3-dimensional Doppler sonography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:257-66. [PMID: 25614399 PMCID: PMC6314288 DOI: 10.7863/ultra.34.2.257] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
OBJECTIVES Three-dimensional (3D)/4-dimensional (4D) sonographic measurement of blood volume flow in transjugular intrahepatic porto systemic shunt revision with the intention of objective assessment of shunt patency. METHODS A total of 17 patients were recruited (12 male and 5 female; mean age, 55 years; range, 30-69 years). An ultrasound system equipped with a 2.0-5.0-MHz probe was used to acquire multivolume 3D/4D color Doppler data sets to assess prerevision and postrevision shunt volume flow. Volume flow was computed offline based on the principle of surface integration of Doppler-measured velocity vectors in a lateral-elevational c-surface positioned at the color flow focal depth (range, 8.0-11.5 cm). Volume flow was compared to routine measurements of the prerevision and postrevision portosystemic pressure gradient. Prerevision volume flow was compared with the outcome to determine whether a flow threshold for revision could be defined. RESULTS Linear regression of data from revised transjugular intrahepatic portosystemic shunt cases showed an inverse correlation between the mean-normalized change in prerevision and postrevision shunt volume flow and the mean-normalized change in the prerevision and postrevision portosystemic pressure gradient (r(2) = 0.51; P = .020). Increased shunt blood flow corresponded to a decreased pressure gradient. Comparison of prerevision flows showed preliminary threshold development at 1534 mL/min, below which a shunt revision may be recommended (P = .21; area under the receiver operating characteristic curve = 0.78). CONCLUSIONS Shunt volume flow measurement with 3D/4D Doppler sonography provides a potential alternative to standard pulsed wave Doppler metrics as an indicator of shunt function and predictor of revision.
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Affiliation(s)
- Stephen Z Pinter
- Department of Radiology, University of Michigan, Ann Arbor, Michigan USA (S.Z.P., J.M.R., O.D.K., P.M.N., M.V.-V., J.B.F.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.)
| | - Jonathan M Rubin
- Department of Radiology, University of Michigan, Ann Arbor, Michigan USA (S.Z.P., J.M.R., O.D.K., P.M.N., M.V.-V., J.B.F.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.)
| | - Oliver D Kripfgans
- Department of Radiology, University of Michigan, Ann Arbor, Michigan USA (S.Z.P., J.M.R., O.D.K., P.M.N., M.V.-V., J.B.F.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.).
| | - Paula M Novelli
- Department of Radiology, University of Michigan, Ann Arbor, Michigan USA (S.Z.P., J.M.R., O.D.K., P.M.N., M.V.-V., J.B.F.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.)
| | - Mario Vargas-Vila
- Department of Radiology, University of Michigan, Ann Arbor, Michigan USA (S.Z.P., J.M.R., O.D.K., P.M.N., M.V.-V., J.B.F.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.)
| | - Anne L Hall
- Department of Radiology, University of Michigan, Ann Arbor, Michigan USA (S.Z.P., J.M.R., O.D.K., P.M.N., M.V.-V., J.B.F.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.)
| | - J Brian Fowlkes
- Department of Radiology, University of Michigan, Ann Arbor, Michigan USA (S.Z.P., J.M.R., O.D.K., P.M.N., M.V.-V., J.B.F.); and GE Healthcare, Milwaukee, Wisconsin USA (A.L.H.)
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48
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Abstract
In patients with cirrhosis, routine laboratory tests for primary hemostasis and coagulation usually show anomalies that are associated with excess bleeding in other settings, in particular low platelet counts and prolonged prothrombin time. However, under conditions similar to those in vivo, primary hemostasis and thrombin production do not appear to be decreased in patients with cirrhosis, particularly when the platelet count is above 75,000/μl. Furthermore, there is laboratory and epidemiological evidence of a mild procoagulant and prothrombotic state in patients with cirrhosis. Bleeding is mainly because of portal hypertension rather than defective hemostasis. There is some evidence that anticoagulation therapy is not associated with an excess of severe bleeding and that it could improve the outcome in patients without portal vein thrombosis. At present, there is no clear evidence that portal vein thrombosis is responsible for the progression of liver disease and that anticoagulation therapy would improve the outcome of patients with portal vein thrombosis.
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Affiliation(s)
- Dominique-C Valla
- DHU UNITY, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy-la-Garenne, France; INSERM, U1149, CRI, Université Paris-Diderot, Paris, France
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49
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Qi X, Dai J, Yang M, Ren W, Jia J, Guo X. Association between Portal Vein Thrombosis and Survival in Non-Liver-Transplant Patients with Liver Cirrhosis: A Systematic Review of the Literature. Gastroenterol Res Pract 2015; 2015:480842. [PMID: 25810714 PMCID: PMC4355112 DOI: 10.1155/2015/480842] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 02/10/2015] [Indexed: 02/07/2023] Open
Abstract
A systematic review of the literature was performed to analyze the association between portal vein thrombosis (PVT) and survival in non-liver-transplant patients with liver cirrhosis. PubMed, EMBASE, and Cochrane Library databases were searched for all relevant papers which evaluated the prognostic value of PVT in predicting the survival of liver cirrhosis. Meta-analyses were not conducted because the ways of data expression and lengths of follow-up were heterogeneous among studies. Overall, 13 papers were included. The 5-day, 6-week, and 1-year mortality were investigated in 1, 3, and 1 studies, respectively; and all of them were not significantly different between cirrhotic patient with and without PVT. By comparison, the 3-year mortality was reported in 1 study; and it was significantly increased by the presence of PVT. The overall mortality was analyzed in 5 studies; and the association with overall mortality and PVT was significant in 4 studies, but not in another one. However, as for the cirrhotic patients undergoing surgical or interventional shunts, the overall mortality was not significantly associated with the presence of PVT in 4 studies. In conclusion, the presence of PVT might be associated with the long-term mortality in non-liver-transplant patients with liver cirrhosis, but not with the short-term mortality.
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Affiliation(s)
- Xingshun Qi
- 1Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China
- 2Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Junna Dai
- 1Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China
| | - Man Yang
- 2Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
- 3Department of Gastroenterology, Songgang People's Hospital, Shenzhen 518105, China
| | - Weirong Ren
- 2Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
- 4Department of Digestive Diseases, Sanmenxia Central Hospital, Henan University of Science and Technology, Xiaoshan Road, Sanmenxia 472000, China
| | - Jia Jia
- 2Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
- 5Department of Emergency, Shaanxi Provincial People's Hospital, Xi'an 710068, China
| | - Xiaozhong Guo
- 1Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China
- *Xiaozhong Guo:
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50
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Raja K, Jacob M, Asthana S. Portal vein thrombosis in cirrhosis. J Clin Exp Hepatol 2014; 4:320-31. [PMID: 25755579 PMCID: PMC4298635 DOI: 10.1016/j.jceh.2013.12.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 12/02/2013] [Indexed: 12/12/2022] Open
Abstract
Portal vein thrombosis (PVT) is being increasingly recognized in patients with advanced cirrhosis and in those undergoing liver transplantation. Reduced flow in the portal vein is probably responsible for clotting in the spleno-porto-mesenteric venous system. There is also increasing evidence that hypercoagulability occurs in advanced liver disease and contributes to the risk of PVT. Ultrasound based studies have reported a prevalence of PVT in 10-25% of cirrhotic patients without hepatocellular carcinoma. Partial thrombosis of the portal vein is more common and may not have pathophysiological consequences. However, there is high risk of progression of partial PVT to complete PVT that may cause exacerbation of portal hypertension and progression of liver insufficiency. It is thus, essential to accurately diagnose and stage PVT in patients waiting for transplantation and consider anticoagulation therapy. Therapy with low molecular weight heparin and vitamin K antagonists has been shown to achieve complete and partial recanalization in 33-45% and 15-35% of cases respectively. There are however, no guidelines to help determine the dose and therapeutic efficacy of anticoagulation in patients with cirrhosis. Anticoagulation therapy related bleeding is the most feared complication but it appears that the risk of variceal bleeding is more likely to be dependent on portal pressure rather than solely related to coagulation status. TIPS has also been reported to restore patency of the portal vein. Patients with complete PVT currently do not form an absolute contraindication for liver transplantation. Thrombectomy or thromboendovenectomy is possible in more than 75% of patients followed by anatomical end-to-end portal anastomosis. When patency of the portal vein and/or superior mesenteric vein is not achieved, only non-anatomical techniques (reno-portal anastomosis or cavo-portal hemitransposition) can be performed. These techniques, which do not fully reverse portal hypertension, are associated with higher morbidity and mortality risks in the short term.
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Key Words
- DVT, deep vein thrombosis
- EVL, endoscopic variceal ligation
- INR, international normalized ratio
- IVC, inferior vena cava
- LMWH, low molecular weight heparin
- MELD, model for end stage liver disease
- MTHFR, methylene-tetrahydrofolate reductase
- PE, pulmonary embolism
- PT, prothrombin time
- PVT, portal vein thrombosis
- SMV, superior mesenteric vein
- TEG, thromboelastography
- TIPS, transjugular intrahepatic portosystemic shunt
- US, ultrasonography
- VKA, vitamin K antagonists
- anticoagulation
- cirrhosis
- portal vein thrombosis
- portocaval hemitransposition
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Affiliation(s)
- Kaiser Raja
- Address for correspondence: Kaiser Raja, Department of Hepatology, Global Integrated Liver Care Program, BGS Global Hospitals, #67 Utarahalli Road, Kengeri, Bangalore 560 060, India.
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