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Guo Y, Dong S, Li M, Tao Y, Lv J, Liu C. A new model of portal vein thrombosis in rats with cirrhosis induced by partial portal vein ligation plus carbon tetrachloride and intervened with rivaroxaban. BMC Gastroenterol 2024; 24:161. [PMID: 38741060 DOI: 10.1186/s12876-024-03253-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 05/02/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND AND AIMS Portal vein thrombosis (PVT) is a common complication of liver cirrhosis that can aggravate portal hypertension. However, there are features of both PVT and cirrhosis that are not recapitulated in most current animal models. In this study, we aimed to establish a stable animal model of PVT and cirrhosis, intervene with anticoagulant, and explore the related mechanism. METHODS First, 49 male SD rats received partial portal vein ligation (PPVL), and 44 survival rats were divided into 6 groups: PPVL control group; 4-week, 6 -week, 8-week, and 10-week model group; and the rivaroxaban (RIVA)-treated group. The rats were intoxicated with or without carbon tetrachloride (CCl4) for 4-10 weeks. Seven normal rats were used as the normal controls. Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels and parameters for blood coagulation were all assayed with kits. Liver inflammation, collagen deposition and hydroxyproline (Hyp) levels were also measured. The extrahepatic macro-PVT was observed via portal vein HE staining, etc. The intrahepatic microthrombi was stained via fibrin immunohistochemistry. The portal blood flow velocity (PBFV) and diameter were detected via color Doppler ultrasound. Vascular endothelial injury was evaluated by von Willebrand Factor (vWF) immunofluorescence. Fibrinolytic activity was estimated by western blot analysis of fibrin and plasminogen activator inhibitor-1 (PAI-1). RESULTS After PPVL surgery and 10 weeks of CCl4 intoxication, a rat model that exhibited characteristics of both cirrhosis and extra and intrahepatic thrombi was established. In cirrhotic rats with PVT, the PBFV decreased, both factors of pro- and anti-coagulation decreased, but with relative hypercoagulable state, vascular endothelial injured, and fibrinolytic activity decreased. RIVA-treated rats had improved coagulation function, increased PBFV and attenuated thrombi. This effect was related to the improvements in endothelial injury and fibrinolytic activity. CONCLUSIONS A new rat model of PVT with cirrhosis was established through partial portal vein ligation plus CCl4 intoxication, with the characteristics of macrothrombi at portal veins and microthrombi in hepatic sinusoids, as well as liver cirrhosis. Rivaroxaban could attenuate PVT in cirrhosis in the model rats. The underlying mechanisms of PVT formation in the rat model and pharmacological action of rivaroxaban are related to the regulation of portal blood flow, coagulant factors, and vascular endothelial cell function.
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Affiliation(s)
- Yanan Guo
- Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Sisi Dong
- Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- Liuhe District Hospital of Traditional Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Meng Li
- Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Yanyan Tao
- Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, China
- Key Laboratory of Liver and Kidney Diseases, Ministry of Education, Shanghai, China
| | - Jing Lv
- Department of Liver Disease, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Chenghai Liu
- Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
- Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, China.
- Key Laboratory of Liver and Kidney Diseases, Ministry of Education, Shanghai, China.
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Iwasaki H, Uehara H, Fujimoto Y, Hasuda H, Kusumoto E, Hisamatsu Y, Yoshida R, Sakaguchi Y, Kusumoto T. Fatal pulmonary embolism after surgery for small intestinal necrosis caused by idiopathic portal vein thrombosis: a case report. Surg Case Rep 2024; 10:90. [PMID: 38635121 PMCID: PMC11026322 DOI: 10.1186/s40792-024-01900-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/15/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Portal vein thrombosis (PVT) and venous thromboembolism (VTE) both result from partial or complete occlusion of a blood vessel by a blood clot. The prognosis of PVT is generally good; however, PVT with VTE, including pulmonary embolism (PE), has a high mortality rate. We report here a case of PE after surgery for small intestinal necrosis caused by idiopathic PVT. CASE PRESENTATION A 69-year-old female attended our hospital with a chief complaint of upper abdominal discomfort, and was diagnosed with necrosis of the small intestine as a result of unexplained PVT. She underwent partial resection of the small intestine. On the second postoperative day, she suffered from respiratory distress and went into cardiopulmonary arrest. The patient recovered following cardiopulmonary resuscitation, but PE was detected. Extracorporeal veno-arterial cardiopulmonary resuscitation and anticoagulation therapy were initiated immediately and the thrombus was aspirated as much as possible. Two days later, extracorporeal veno-arterial cardiopulmonary resuscitation was withdrawn and anticoagulation therapy was continued. The patient subsequently recovered with no neurological damage and was discharged on day 26 after the above procedure. CONCLUSIONS Idiopathic PVT is often associated with VTE, and a prompt diagnosis and intervention may result in a good prognosis.
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Affiliation(s)
- Hitoshi Iwasaki
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan.
| | - Hideo Uehara
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Yugo Fujimoto
- Department of Cardiology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Hirofumi Hasuda
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Eiji Kusumoto
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Yuichi Hisamatsu
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Rintaro Yoshida
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Yoshihisa Sakaguchi
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Tetsuya Kusumoto
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
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Georgescu D, Ancusa OE, Azoulay D, Lascu A, Ionita I, Calamar-Popovici D, Ionita M, Rosca CI, Brează GM, Reisz D, Lighezan D. Portal Vein Thrombosis in Patients with Liver Cirrhosis: What Went Wrong? Int J Gen Med 2023; 16:3889-3906. [PMID: 37662503 PMCID: PMC10473422 DOI: 10.2147/ijgm.s413438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/10/2023] [Indexed: 09/05/2023] Open
Abstract
Purpose This study aimed to explore inflammatory biomarkers, stool's functional bacterial groups and their possible link to portal vein thrombosis (PVT) in patients with liver cirrhosis (LC). Materials and Methods An observational study of 300 participants: 200 inhospital cirrhotic patients, who met inclusion criteria, equally assigned into two groups, based on the presence or absence of PVT and 100 healthy controls was carried out. Results The PVT group displayed significant differences related to older age, cigarettes smoking history, emergency admission, higher Child-Pugh score, metabolic related disorders and nonalcoholic fatty liver disease, as well as non-obstructive aspects, with chronic thrombi. The PVT group exhibited significant differences related to biomarkers such as tumor necrosis factor (TNF)-alpha, C-reactive protein (CRP), D-dimers (D-D), as well as gut overall dysbiosis (DB) and alteration of different functional bacterial groups of the gut microbiota. Strong positive correlations were observed between PVT severity, and TNF-alpha, CRP, D-D as well as lipopolysaccharide (LPS) positive bacteria. Esophageal varices, age and abdominal pain were independent predictors for PVT severity as well as CRP, TNF-alpha and D-D. Conclusion Patients with LC and PVT displayed elevation of TNF-alpha, CRP, D-D alterations of the functional gut microbiota, as well as several morphological and clinical particularities. Although the LPS positive gut microbiota was linked to inflammatory biomarkers and PVT severity, it was not proven to be an independent predictor of the PVT severity like CRP, TNF-alpha and D-D.
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Affiliation(s)
- Doina Georgescu
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Oana-Elena Ancusa
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Daniel Azoulay
- Hepato-Biliary Center, Paul-Brousse Hospital, Paris-Saclay University, Villejuif, France
| | - Ana Lascu
- Department of Functional Sciences, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Ioana Ionita
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Despina Calamar-Popovici
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Mihai Ionita
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Ciprian Ilie Rosca
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Gelu-Mihai Brează
- Department IX of Surgery I, Compartment of Hepatic-Biliary-Pancreatic Surgery, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Daniela Reisz
- Department of Neurosciences, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Daniel Lighezan
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
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Dröes FC, Suchodolski JS, Steiner JM, Lidbury JA. Prevalence of portal vein and splanchnic venous thrombosis in dogs with chronic hepatitis. J Small Anim Pract 2023; 64:375-383. [PMID: 36973881 DOI: 10.1111/jsap.13597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 11/24/2022] [Accepted: 01/24/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVES Alterations in haemostasis have been described in dogs and humans with chronic hepatitis. Portal vein thrombosis is a recognised complication of chronic hepatitis in humans; however, its prevalence in dogs with chronic hepatitis has not been reported. We aimed to estimate the prevalence of, and describe clinical and laboratory data of dogs with chronic hepatitis and portal vein thrombosis and splanchnic venous thrombosis. MATERIALS AND METHODS Retrospective cross-sectional study. Medical records of dogs admitted to a veterinary teaching hospital between 2009 and 2019 were reviewed. Dogs were included if chronic hepatitis was histopathologically confirmed, and if diagnostic imaging or necropsy indicated the presence of thrombosis. Clinical and laboratory data (i.e. haematology, biochemistry, coagulation panels) were recorded. Descriptive statistics were used to characterise dogs with and without thrombosis. RESULTS Records from 136 dogs with chronic hepatitis were identified. Three of these dogs, 2.2% (95% confidence interval: 0.8 to 6.3%) all females, were diagnosed with portal vein thrombosis. Five dogs in total, (3.7%; 95% confidence interval: 1.6 to 8.3%), including three with portal vein thrombosis, all females, were diagnosed with splanchnic venous thrombosis. Dogs with portal vein and splanchnic venous thrombosis often had hyperbilirubinaemia, increased serum gamma-glutamyl transferase activity, and decreased plasma antithrombin 3 activity. They also had relatively high alternative Child-Pugh scores for dogs (median 6 out of 13). CLINICAL SIGNIFICANCE Portal vein and splanchnic venous thrombosis are potentially serious complications that were identified in a relatively low proportion of dogs with chronic hepatitis.
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Affiliation(s)
- F C Dröes
- Gastrointestinal Laboratory, Texas A&M University - College of Veterinary Medicine & Biomedical Sciences, 4474 TAMU, College Station, TX, 77843, USA
| | - J S Suchodolski
- Gastrointestinal Laboratory, Texas A&M University - College of Veterinary Medicine & Biomedical Sciences, 4474 TAMU, College Station, TX, 77843, USA
| | - J M Steiner
- Gastrointestinal Laboratory, Texas A&M University - College of Veterinary Medicine & Biomedical Sciences, 4474 TAMU, College Station, TX, 77843, USA
| | - J A Lidbury
- Gastrointestinal Laboratory, Texas A&M University - College of Veterinary Medicine & Biomedical Sciences, 4474 TAMU, College Station, TX, 77843, USA
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Kasmikha L, Khan N, Almajed MR, Entz A, Jafri SM. Hepatitis C Cirrhosis, Hepatitis B Superimposed Infection, and the Emergence of an Acute Portal Vein Thrombosis: A Case Report. Cureus 2023; 15:e39839. [PMID: 37397643 PMCID: PMC10314798 DOI: 10.7759/cureus.39839] [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] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
Acute portal vein thrombosis (PVT) is a complication of liver cirrhosis. The presence of viral infections such as hepatitis B (HBV) and hepatitis C (HCV) can further increase cirrhotic patients' risk of developing PVT, especially in the rare case when there is superinfection with both HBV and HCV. We present a patient with HCV cirrhosis whose clinical condition was decompensated secondary to the development of superimposed HBV infection, who developed acute PVT during hospitalization. This case offers a unique presentation of acute PVT that developed within several days of hospitalization for decompensated liver disease, as proven by the interval absence of portal venous flow on repeat imaging. Despite the workup on the initial presentation being negative for PVT, reconsideration of differentials after the change in our patient's clinical status led to the diagnosis. Active HBV infection was likely the initial trigger for the patient's cirrhosis decompensation and presentation; the subsequent coagulopathy and alteration in the portal blood flow triggered the development of an acute PVT. The risk for both prothrombotic and antithrombotic complications remains high in patients with cirrhosis, a risk that is vastly increased by the presence of superimposedinfections. The diagnosis of thrombotic complications such as PVT can be challenging, thus stressing the importance of repeat imaging in instances where clinical suspicion remains high despite negative imaging. Anticoagulation should be considered for cirrhotic patients with PVT on an individual basis for both prevention and treatment. Prompt diagnosis, early intervention, and close monitoring of patients with PVT are crucial for improving clinical outcomes. The goal of this report is to illustrate diagnostic challenges that accompany the diagnosis of acute PVT in cirrhosis, as well as discuss therapeutic options for optimal management of this condition.
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Affiliation(s)
- Lauren Kasmikha
- Internal Medicine, Wayne State University School of Medicine, Detroit, USA
| | - Naoshin Khan
- Internal Medicine, Henry Ford Hospital, Detroit, USA
| | | | - Abigail Entz
- Internal Medicine, Henry Ford Hospital, Detroit, USA
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Mukund A, Marri UK, Jindal A, Choudhury A, Patidar Y, Sarin SK. Safety and Efficacy of Transjugular Intrahepatic Portosystemic Shunt for Non-tumoral Cirrhotic Portal Vein Thrombosis Not Responding to Anticoagulation Therapy. Dig Dis Sci 2023:10.1007/s10620-023-07930-4. [PMID: 37169934 DOI: 10.1007/s10620-023-07930-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 03/14/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVES To evaluate the feasibility, safety, and efficacy of add-on transjugular-intrahepatic-portosystemic shunt (TIPS) for portal vein recanalization (PVR) in cirrhotic patients with non-tumoral chronic portal vein thrombosis (PVT) after 6 months of monitored anticoagulation therapy (ACT). METHODS We conducted a retrospective search of the hospital database for patients who underwent TIPS for persistent PVT despite 6 months of ACT (January 2011 to August 2021). These patients were compared to control group (ACT group; no TIPS but continued on ACT). Post-TIPS periodic assessment was done to look for clinical outcome, PVR (using contrast-enhanced CT scan), and complications. RESULTS A total of 90 patients were analyzed. Thirty-six patients in TIPS group and 54 patients in ACT group. TIPS was successfully performed in all patients. TIPS group showed complete recanalization of portal vein in 77.8%, partial recanalization in 16.7%, and stable thrombus in 5.5% of the patients. TIPS thrombosis was seen in 3 patients, all underwent successful endovascular thrombolysis. Seven patients developed post-TIPS hepatic encephalopathy and were managed conservatively. In contrast, no patient in ACT group achieved PVR on 12-month follow-up. After propensity score matching, patients in TIPS group showed significantly lower incidence of variceal re-bleeding (22.2% vs. 77.8%, p = 0.03) and refractory ascites (11.1% vs. 51.9%, p < 0.01) with significantly better 12-month survival as compared to ACT group (88.9% vs. 69.4%, p = 0.04). CONCLUSION TIPS in cirrhotic patients with PVT result in superior recanalization rates, better control of ascites, and variceal re-bleeding resulting in better survival. TIPS may be considered a preferred therapy after anticoagulation failure. CLINICAL IMPACT TIPS is associated with good technical and clinical success in patients of cirrhosis with PVT and should be considered in patients not responding to ACT.
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Affiliation(s)
- Amar Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India
| | - Uday Kumar Marri
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India
| | - Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India.
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India
| | - Yashwant Patidar
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India
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Oktaviana J, Lui B, Ho P, Lim HY. A 10-year Australian experience of rare intraabdominal venous thrombosis with comparison to deep vein thrombosis and pulmonary embolism. Blood Coagul Fibrinolysis 2023; 34:191-198. [PMID: 36966765 DOI: 10.1097/mbc.0000000000001213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
Abstract
OBJECTIVE Intra-abdominal venous thromboembolism is rare with heterogeneous management. We aim to evaluate these thrombosis and compare them to deep vein thrombosis and/or pulmonary embolism. METHOD A 10-year retrospective evaluation of consecutive venous thromboembolism presentations (January 2011-December 2020) at Northern Health, Australia, was conducted. A subanalysis of intraabdominal venous thrombosis involving splanchnic, renal and ovarian veins was performed. RESULTS There were 3343 episodes including 113 cases of intraabdominal venous thrombosis (3.4%) - 99 splanchnic vein thrombosis, 10 renal vein thrombosis and 4 ovarian vein thrombosis. Of the splanchnic vein thrombosis presentations, 34 patients (35 cases) had known cirrhosis. Patients with cirrhosis were numerically less likely to be anticoagulated compared to noncirrhotic patients (21/35 vs. 47/64, P = 0.17). Noncirrhotic patients ( n = 64) were more likely to have malignancy compared to those with deep vein thrombosis and/or pulmonary embolism (24/64 vs. 543/3230, P < 0.001), including 10 patients diagnosed at time of splanchnic vein thrombosis presentation. Cirrhotic patients reported more recurrent thrombosis/clot progression (6/34) compared to noncirrhotic patients (3/64) (15.6 vs. 2.3 events/100-person-years; hazard ratio 4.7 (95% confidence interval 1.2-18.9), P = 0.030) and other venous thromboembolism patients (2.6/100-person-years; hazard ratio 4.7, 95% confidence interval 2.1-10.7; P < 0.001) with comparable major bleeding rates. All renal vein thrombosis were provoked including five malignant-related cases while three ovarian vein thrombosis occurred postpartum. No recurrent thrombotic or bleeding complications were reported in renal vein thrombosis and ovarian vein thrombosis. CONCLUSION These rare intraabdominal venous thromboses are often provoked. Splanchnic vein thrombosis (SVT) patients with cirrhosis have a higher rate of thrombotic complications, while SVT without cirrhosis was associated with more malignancy. Given the concurrent comorbidities, careful assessment and individualized anticoagulation decision is needed.
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Affiliation(s)
- Jesica Oktaviana
- Northern Clinical Pathology, Thrombosis and Radiology (NECTAR) Research Group (Northern Pathology Victoria), Department of Haematology, Northern Health, Epping
| | - Brandon Lui
- Northern Clinical Pathology, Thrombosis and Radiology (NECTAR) Research Group (Northern Pathology Victoria), Department of Haematology, Northern Health, Epping
| | - Prahlad Ho
- Northern Clinical Pathology, Thrombosis and Radiology (NECTAR) Research Group (Northern Pathology Victoria), Department of Haematology, Northern Health, Epping
- Australian Centre for Blood Diseases, Monash University, Melbourne
- Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Hui Y Lim
- Northern Clinical Pathology, Thrombosis and Radiology (NECTAR) Research Group (Northern Pathology Victoria), Department of Haematology, Northern Health, Epping
- Australian Centre for Blood Diseases, Monash University, Melbourne
- Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
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Transjugular Intrahepatic Portosystemic Shunt in Chronic Portal Vein Thrombosis-From Routine Recommendations to Demanding Scenarios. Diagnostics (Basel) 2022; 12:diagnostics12123100. [PMID: 36553107 PMCID: PMC9777205 DOI: 10.3390/diagnostics12123100] [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: 10/28/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
Portal vein thrombosis (PVT), particularly the presence of portal cavernoma, was traditionally considered a relative contraindication for transjugular intrahepatic portosystemic shunting (TIPS) due to the technical difficulties in accessing and maneuvering the portal vein and avoiding the high risk for bleeding periportal collaterals. However, the last decade has seen a surge in the number of studies-mostly case reports and small series of patients-demonstrating that TIPS is not only technically feasible in the vast majority of these patients but also provides effective and long-term control of symptoms associated with portal hypertension in cases refractory to the standard line of therapy. The present article aims to provide a concise but exhaustive overview of the role and the standard and technically difficult TIPS placement scenarios in patients with chronic non-malignant PVT and with and without underlying liver disease. The review is strategically punctuated by exemplary instances from the authors' experience.
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Durgham A, Tessier S, Ido F, Longo S, Nanda S. Congenital Portosystemic Shunts in Cirrhosis and Portal Vein Thrombosis: A Case Report. Cureus 2022; 14:e31587. [DOI: 10.7759/cureus.31587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 11/18/2022] Open
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10
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Clinical and imaging predictors of the natural course of bland portal vein thrombus in cirrhotic patients. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 47:3724-3732. [PMID: 35943518 DOI: 10.1007/s00261-022-03626-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 07/13/2022] [Accepted: 07/15/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Portal vein thrombus (PVT) in cirrhotic patients is associated with worsening portal hypertension, leads to increased complexity of necessary interventions such as transjugular liver portosystemic shunt or liver transplantation, and is associated with worse outcomes after liver transplantation. Additionally, there are no established consensus guidelines for management of bland PVT in cirrhotic patients, which currently exists on a spectrum and is patient and provider dependent. PURPOSE The aim of this study was to determine whether there are associations between key clinical and imaging variables and bland PVT burden over time. MATERIAL AND METHODS This exploratory, retrospective, single-center study included patients who underwent two or more multiphase CT or MRI examinations between 1/1/2013 and 12/31/2019 and had a diagnosis of PVT. Three readers independently evaluated all index and follow-up examinations for PVT burden using a proposed 8-point scale and the established Yerdel score. Key clinical factors were collected from the electronic medical record. The PVT burden over time and the association of this burden with key clinical and imaging variables were assessed using logistic regression models. RESULTS 138 patients with cirrhosis and bland PVT were included in the analyses. Median age was 60 years (interquartile range 55-67; 90 men) and median follow-up time was 19.6 months. At baseline, the mean score was 2.31 (± 1.44) and at the final follow-up examination, the mean score was 2.52 (± 1.99). Baseline occlusion level was the only statistically significant association with worsening PVT burden in all four vascular territories (p-value < 0.0001). Anticoagulation status did not have a statistically significant association with change in thrombus burden in any vascular territory or cumulative thrombus burden across all territories (p-value 0.11-0.43). CONCLUSION In conclusion, our study shows that in cirrhotic patients with bland PVT, the thrombus burden did not change significantly over time and baseline thrombus burden is the only clinical factor significantly associated with increasing burden over time.
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Palomares JPDL, Barajas IG, León VJ, Estrada IE, Guzmán Barba JA, Orozco Álvarez-Malo JO. Portomesenteric venous thrombosis post gastric sleeve. J Surg Case Rep 2022; 2022:rjac435. [PMID: 36158242 PMCID: PMC9491872 DOI: 10.1093/jscr/rjac435] [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: 08/18/2022] [Accepted: 08/29/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
The gastric sleeve is the most performed bariatric surgery, and several studies have shown a good safety profile. Among its main postoperative complications are bleeding, leak, stenosis, reflux and to a lesser extent, portomesenteric venous thrombosis (1%). More than 80% of this entity occur after discharge. Diagnosis is difficult because it does not have characteristic symptoms or laboratory abnormalities. A 30-year-old male with a body mass index of 40.2 kg/m2, submitted to gastric sleeve, developing tachycardia, abdominal pain and oral intolerance on the eighth postoperative day. Contrast-enhanced abdominopelvic tomography revealed thrombosis of the portal, mesenteric and splenic veins. Portomesenteric venous thrombosis managed with resection, laparoscopic entero–entero anastomosis and anticoagulation. Although the risk of presenting portomesenteric venous thrombosis is relatively low, its complications are serious and life-threatening, in addition to an increased prevalence in bariatric surgeries.
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Affiliation(s)
| | - Iván González Barajas
- Bariatric Surgery Department, Instituto Nefrológico de Tijuana, Tijuana, Baja California, Mexico
| | - Valeria Jaime León
- Bariatric Surgery Department, Instituto Nefrológico de Tijuana, Tijuana, Baja California, Mexico
| | | | - José A Guzmán Barba
- Bariatric Surgery Department, Instituto Nefrológico de Tijuana, Tijuana, Baja California, Mexico
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Shirai S, Ueda T, Sugihara F, Yasui D, Saito H, Furuki H, Kim S, Yoshida H, Yokobori S, Hayashi H, Kumita SI. Transileocolic endovascular treatment by a hybrid approach for severe acute portal vein thrombosis with bowel necrosis: Two case reports. World J Clin Cases 2022; 10:1876-1882. [PMID: 35317162 PMCID: PMC8891780 DOI: 10.12998/wjcc.v10.i6.1876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/22/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute portal vein thrombosis (PVT) with bowel necrosis is a fatal condition with a 50%-75% mortality rate. This report describes the successful endovascular treatment (EVT) of two patients with severe PVT.
CASE SUMMARY The first patient was a 22-year-old man who presented with abdominal pain lasting 3 d. The second patient was a 48-year-old man who presented with acute abdominal pain. Following contrast-enhanced computed tomography, both patients were diagnosed with massive PVT extending to the splenic and superior mesenteric veins. Hybrid treatment (simultaneous necrotic bowel resection and EVT) was performed in a hybrid operating room (OR). EVTs, including aspiration thrombectomy, catheter-directed thrombolysis (CDT), and continuous CDT, were performed via the ileocolic vein under laparotomy. The portal veins were patent 4 and 6 mo posttreatment in the 22-year-old and 48-year-old patients, respectively.
CONCLUSION Hybrid necrotic bowel resection and transileocolic EVT performed in a hybrid OR is effective and safe.
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Affiliation(s)
- Sayaka Shirai
- Department of Radiology, Nippon Medical School Hospital, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School Hospital, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Fumie Sugihara
- Department of Radiology, Nippon Medical School Hospital, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Daisuke Yasui
- Department of Radiology, Nippon Medical School Musashi Kosugi Hospital, Kawasaki-shi 211-8533, Kanagawa, Japan
| | - Hidemasa Saito
- Department of Radiology, Nippon Medical School Hospital, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Hiroyasu Furuki
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Tamanagayama Hospital, Tama-shi 206-8512, Tokyo, Japan
| | - Shiei Kim
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Hospital, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Hiromitsu Hayashi
- Department of Radiology, Nippon Medical School Hospital, Bunkyo-ku 113-8603, Tokyo, Japan
| | - Shin-ichiro Kumita
- Department of Radiology, Nippon Medical School Hospital, Bunkyo-ku 113-8603, Tokyo, Japan
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13
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Martin A, Struble S, Prado A, Robinson J, Goddard J, Smith T. A Case of Portal Vein Thrombosis in a Patient With Methylenetetrahydrofolate Reductase A1298C Polymorphism. Cureus 2022; 14:e21743. [PMID: 35251815 PMCID: PMC8890599 DOI: 10.7759/cureus.21743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2022] [Indexed: 11/18/2022] Open
Abstract
Portal vein thrombosis (PVT) is a prothrombotic state caused by blood flow stasis, vascular injury, and/or hypercoagulability, resulting in partial or complete occlusion of the portal vein. PVT is a rare diagnosis, particularly among those without liver disease. Typical risk factors for PVT include cirrhosis, hepatocellular carcinoma, myeloproliferative neoplasms, other malignancies, oral contraceptive use, bowel infections, and inherited hypercoagulable disorders. The goal of this study is to analyze a case of PVT in a patient in which no clear etiology could be identified and to evaluate whether the patient’s methylenetetrahydrofolate reductase (MTHFR) polymorphism may have been a risk factor. This is a case of a 44-year-old female with a history of irritable bowel syndrome, hypertension, hyperlipidemia, sleep apnea, gastric bypass surgery, and MTHFR polymorphism who presented to a walk-in clinic with five days of severe abdominal pain associated with diarrhea, nausea, and anorexia. Hypertension and tenderness over the right lower quadrant prompted a referral to the emergency department for evaluation of possible appendicitis. A contrasted computerized tomography (CT) scan of the abdomen and pelvis revealed a normal appendix and acute portal vein thrombosis. She was then admitted for treatment with intravenous (IV) heparin, fluids, and pain management. After an uneventful three-day hospital course, the patient was discharged on rivaroxaban with a plan to continue anticoagulation therapy for six months and follow up with a hematologist, who later confirmed the patient did not have any inherited hypercoagulable disorders. It is unclear whether the patient’s MTHFR polymorphism prompted her PVT as existing data on MTHFR’s effects are limited and conflicting. One cannot conclude that MTHFR caused a state of hyperhomocysteinemia to prompt hypercoagulability, as this has not been consistently proven in current literature, and the patient’s homocysteine levels were not measured at the time of diagnosis. This case illustrates that further research on the various MTHFR polymorphisms and their effects on coagulation, potentially via homocysteinemia, is warranted. Further research on the MTHFR polymorphisms may help determine whether providers should test for MTHFR in the evaluation of thrombotic risk factors and may help optimize the treatment of thrombotic events for affected individuals.
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14
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Knight GM, Clark J, Boike JR, Maddur H, Ganger DR, Talwar A, Riaz A, Desai K, Mouli S, Hohlastos E, Garcia Pagan JC, Gabr A, Stein B, Lewandowski R, Thornburg B, Salem R. TIPS for Adults Without Cirrhosis With Chronic Mesenteric Venous Thrombosis and EHPVO Refractory to Standard-of-Care Therapy. Hepatology 2021; 74:2735-2744. [PMID: 34021505 DOI: 10.1002/hep.31915] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/06/2021] [Accepted: 05/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Extrahepatic portal vein occlusion (EHPVO) from portal vein thrombosis is a rare condition associated with substantial morbidity and mortality. The purpose of this study is to investigate the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) for the treatment of chronic EHPVO, cavernomatosis, and mesenteric venous thrombosis in adults without cirrhosis who are refractory to standard-of-care therapy. APPROACH AND RESULTS Thirty-nine patients with chronic EHPVO received TIPS. Laboratory parameters and follow-up were assessed at 1, 3, 6, 12, and 24 months, and every 6 months thereafter. Two hepatologists adjudicated symptom improvement attributable to mesenteric thrombosis and EHPVO before/after TIPS. Kaplan-Meier was used to assess primary and overall TIPS patency, assessing procedural success. Adverse events, radiation exposure, hospital length-of-stay and patency were recorded. Cavernoma was present in 100%, with TIPS being successful in all cases using splenic, mesenteric, and transhepatic approaches. Symptom improvement was noted in 26 of 30 (87%) at 6-month follow-up. Twelve patients (31%) experienced TIPS thrombosis. There were no significant long-term laboratory adverse events or deaths. At 36 months, freedom from primary TIPS thrombosis was 63%; following secondary interventions, overall patency was increased to 81%. CONCLUSIONS TIPS in chronic, noncirrhotic EHPVO with cavernomas and mesenteric venous thrombosis is technically feasible and does not adversely affect liver function. Most patients demonstrate subjective and objective benefit from TIPS. Improvement in patency rates are needed with proper timing of adjuvant anticoagulation.
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Affiliation(s)
- Gabriel M Knight
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Jeffrey Clark
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Justin R Boike
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Haripriya Maddur
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Daniel R Ganger
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Abhinav Talwar
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Ahsun Riaz
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Kush Desai
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Samdeep Mouli
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Elias Hohlastos
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Juan-Carlos Garcia Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders, Hamburg, Germany
| | - Ahmed Gabr
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Brady Stein
- Department of Medicine, Division of Hematology, Northwestern University, Chicago, IL, USA
| | - Robert Lewandowski
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Bartley Thornburg
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Riad Salem
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
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15
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Kamposioras K, Geraghty J, Appleyard J, Dawod M, Papadimitriou K, Lamarca A, Anthoney A. Pancreaticobiliary Malignancies in the Emergency Room: Management of Acute Complications and Oncological Emergencies. J Gastrointest Cancer 2021; 53:1050-1065. [PMID: 34648136 PMCID: PMC9630225 DOI: 10.1007/s12029-021-00718-7] [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] [Accepted: 09/22/2021] [Indexed: 11/29/2022]
Abstract
Background Management of pancreaticobiliary (PB) malignancies remains a clinical challenge. In this review, we focus on the management of oncological emergencies in PB malignancies and the potential complication of associated therapeutic interventions. Methods Biobliographic review of current evidence on the management of oncological emergencies, their potential complications, as well as synthesis of recommendations was performed. The pathogenesis, frequency, related symptoms as well as appropriate investigations are presented. Results The oncologic emergencies in PB patients were summarised in six categories: (1) hematological (including febrile neutropaenia, thrombocytopenia, coagulopathies), (2) gastrointestinal (gastric outlet and biliary obstruction, gastrointestinal bleeding), (3) thromboembolic events, (4) ascites, (5) metabolic disorders and (6) neurologic complications. The pathogenesis, frequency, related symptoms as well as appropriate investigations are also presented. Conclusion Patients with PB malignancies are at increased risk of a wide variation of medical emergencies. Clinical knowledge, early recognition and collaboration with the relevant specialties are critical to manage these complications effectively, tailoring overall management around the actual prognosis and individuals’ expectations.
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Affiliation(s)
| | - Joe Geraghty
- Department of Gastroenterology, Manchester Royal Infirmary, Manchester, UK
| | | | - Mohammed Dawod
- The Christie NHS Foundation Trust, Manchester, Greater Manchester, UK
| | | | - Angela Lamarca
- The Christie NHS Foundation Trust, Manchester, Greater Manchester, UK.,Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alan Anthoney
- Leeds Institute of Medical Research, St James' Institute of Oncology, St James' University Hospital, University of Leeds, Leeds, LS9 7TF, UK.
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16
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Kim J, Randhawa H, Sands D, Lambe S, Puglia M, Serrano PE, Pinthus JH. Muscle-Invasive Bladder Cancer in Patients with Liver Cirrhosis: A Review of Pertinent Considerations. Bladder Cancer 2021. [DOI: 10.3233/blc-211536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The incidence of liver cirrhosis is increasing worldwide. Patients with cirrhosis are generally at a higher risk of harbouring hepatic and non-hepatic malignancies, including bladder cancer, likely due to the presence of related risk factors such as smoking. Cirrhosis can complicate both the operative and non-surgical management of bladder cancer. For example, cirrhotic patients undergoing abdominal surgery generally demonstrate worse postoperative outcomes, and chemotherapy in patients with cirrhosis often requires dose reduction due to its direct hepatotoxic effects and reduced hepatic clearance. Multiple other considerations in the peri-operative management for cirrhosis patients with muscle-invasive bladder cancer must be taken into account to optimize outcomes in these patients. Unfortunately, the current literature specifically related to the treatment of cirrhotic bladder cancer patients remains sparse. We aim to review the literature on treatment considerations for this patient population with respect to perioperative, surgical, and adjuvant management.
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Affiliation(s)
- John Kim
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - David Sands
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Shahid Lambe
- Division of Urology, McMaster University, Hamilton, ON, Canada
- McMaster Institute of Urology, St. Joseph’s Hospital, Hamilton, ON, Canada
| | - Marco Puglia
- Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
| | | | - Jehonathan H. Pinthus
- Division of Urology, McMaster University, Hamilton, ON, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
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17
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Swinson B, Waters PS, Webber L, Nathanson L, Cavallucci DJ, O'Rourke N, Bryant RD. Portal vein thrombosis following elective laparoscopic splenectomy: incidence and analysis of risk factors. Surg Endosc 2021; 36:3332-3339. [PMID: 34331132 DOI: 10.1007/s00464-021-08649-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 07/16/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Minimally invasive splenectomy is now well established for a wide range of pathologies. Portal vein thrombosis (PVT) is increasingly being recognised as a complication of splenectomy. The aim was to determine the incidence and risk factors for PVT after laparoscopic splenectomy. METHODS All cases of elective laparoscopic splenectomy performed from 1993 to 2020 were reviewed. Parameters recorded included demographics, diagnostic criterion and post-operative outcomes. Data were analysed using Minitab V18 with a p < 0.05 considered significant. RESULTS 210 patients (103 female, 107 male) underwent laparoscopic splenectomy (14 to 85 years). A major proportion of cases were performed for ITP (n = 77, p = 0.012) followed by lymphoma (n = 28), indeterminate lesions (n = 21) and myelofibrosis (n = 19). Ten patients developed symptomatic portal vein thrombosis (4.8%). Patients presented most commonly with pain and fever and diagnosis was confirmed by computed tomography (CT) or ultrasonography (USS). There were 10 conversions (4.8%) to open and two postoperative deaths, one from PVT and one from pneumonia. The remaining nine patients were successfully treated with anticoagulation. Of 19 patients with myelofibrosis, six patients developed PVT (p = 0.0002). Patients who developed PVT had significantly greater specimen weights (1773 g vs 348 g, p < 0.001). Forty-three patients had a specimen weight of 1 kg or greater, and of these 9 developed portal vein thrombosis (21%), versus one with PVT of 155 with a specimen weight of less than 1 kg (p < 0.0001). Myelofibrosis (p = 0.0039), specimen weight (p < 0.001) and mean platelet count (p = 0.0049) were predictive of PVT. CONCLUSION A high index of suspicion for this complication should be maintained and prompt treatment with anticoagulation. High-risk patients should be considered for prophylactic anticoagulation and routine imaging of the portal vein.
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Affiliation(s)
- Benjamin Swinson
- Department of Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia
| | - Peadar S Waters
- Department of Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.
| | - Laurence Webber
- Department of Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia
| | - Les Nathanson
- Department of Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,Department of Surgery, Wesley Hospital, Auchenflower, QLD, 4066, Australia
| | - David J Cavallucci
- Department of Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,Department of Surgery, Wesley Hospital, Auchenflower, QLD, 4066, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Nicholas O'Rourke
- Department of Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,Department of Surgery, Wesley Hospital, Auchenflower, QLD, 4066, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Richard D Bryant
- Department of Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,St Vincent's Northside Medical Centre, St Vincent's Private Hospital Northside, 627 Rode Road, Chermside, QLD, 4032, Australia
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18
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Ilcewicz HN, Martello JL, Piechowski K. Evaluation of the efficacy and safety of direct oral anticoagulants in the treatment of portal vein thrombosis. Eur J Gastroenterol Hepatol 2021; 33:911-916. [PMID: 33079786 PMCID: PMC8371984 DOI: 10.1097/meg.0000000000001958] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the efficacy and safety of direct oral anticoagulants vs. warfarin for portal vein thrombosis treatment. METHODS This was a single-center, retrospective study. Adult patients initiated on a direct oral anticoagulant or warfarin for treatment of a new portal vein thrombosis were included. The primary failure outcome was the absolute difference in recurrent thromboembolic events 90 days following initiation of a direct oral anticoagulant vs. warfarin. The primary safety outcome was the absolute difference in bleeding events 90 days following initiation of a direct oral anticoagulant vs. warfarin. Descriptive statistics, Fisher's exact, and Student's t-tests were utilized as appropriate. RESULTS Thirty-three patients were included. Thirteen (39.4%) patients received direct oral anticoagulants, and 20 (60.6%) received warfarin. None of the patients receiving direct oral anticoagulants experienced a primary failure event compared to four receiving warfarin (P < 0.001). None of the patients receiving direct oral anticoagulants experienced a primary safety event vs. one receiving warfarin (P < 0.001). CONCLUSION Direct oral anticoagulants appear to be effective and safe in the treatment of portal vein thrombosis and in preventing recurrent thromboembolic events. Future studies with larger sample sizes are warranted to confirm direct oral anticoagulants' efficacy in portal vein thrombosis.
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Affiliation(s)
- Haley N. Ilcewicz
- St. Louis College of Pharmacy at University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri
| | - Jay L. Martello
- West Virginia University School of Pharmacy, Morgantown, West Virginia, USA
| | - Kara Piechowski
- West Virginia University Medicine, Morgantown, West Virginia, USA
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19
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Zhan C, Prabhu V, Kang SK, Li C, Zhu Y, Kim S, Olsen S, Jacobson IM, Dagher NN, Carney B, Hickey RM, Taslakian B. Comparison of Non-Tumoral Portal Vein Thrombosis Management in Cirrhotic Patients: TIPS Versus Anticoagulation Versus No Treatment. J Clin Med 2021; 10:jcm10112316. [PMID: 34073236 PMCID: PMC8198761 DOI: 10.3390/jcm10112316] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 04/21/2021] [Accepted: 05/11/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There is a lack of consensus in optimal management of portal vein thrombosis (PVT) in patients with cirrhosis. The purpose of this study is to compare the safety and thrombosis burden change for cirrhotic patients with non-tumoral PVT managed by transjugular intrahepatic portosystemic shunt (TIPS) only, anticoagulation only, or no treatment. METHODS This single-center retrospective study evaluated 52 patients with cirrhosis and non-tumoral PVT managed by TIPS only (14), anticoagulation only (11), or no treatment (27). The demographic, clinical, and imaging data for patients were collected. The portomesenteric thrombosis burden and liver function tests at early follow-up (6-9 months) and late follow-up (9-16 months) were compared to the baseline. Adverse events including bleeding and encephalopathy were recorded. RESULTS The overall portomesenteric thrombosis burden improved in eight (72%) TIPS patients, three (27%) anticoagulated patients, and two (10%) untreated patients at early follow-up (p = 0.001) and in seven (78%) TIPS patients, two (29%) anticoagulated patients, and three (17%) untreated patients in late follow-up (p = 0.007). No bleeding complications attributable to anticoagulation were observed. CONCLUSION TIPS decreased portomesenteric thrombus burden compared to anticoagulation or no treatment for cirrhotic patients with PVT. Both TIPS and anticoagulation were safe therapies.
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Affiliation(s)
- Chenyang Zhan
- Division of Vascular Interventional Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.Z.); (C.L.); (Y.Z.); (R.M.H.)
| | - Vinay Prabhu
- Division of Abdominal Imaging, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (V.P.); (S.K.K.); (S.K.)
| | - Stella K. Kang
- Division of Abdominal Imaging, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (V.P.); (S.K.K.); (S.K.)
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Clayton Li
- Division of Vascular Interventional Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.Z.); (C.L.); (Y.Z.); (R.M.H.)
| | - Yuli Zhu
- Division of Vascular Interventional Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.Z.); (C.L.); (Y.Z.); (R.M.H.)
| | - Sooah Kim
- Division of Abdominal Imaging, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (V.P.); (S.K.K.); (S.K.)
| | - Sonja Olsen
- Hepatology Section, Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA; (S.O.); (I.M.J.)
| | - Ira M. Jacobson
- Hepatology Section, Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, NY 10016, USA; (S.O.); (I.M.J.)
| | - Nabil N. Dagher
- Transplant Institute, Department of Surgery, NYU Grossman School of Medicine, New York, NY 10016, USA;
| | - Brendan Carney
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - Ryan M. Hickey
- Division of Vascular Interventional Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.Z.); (C.L.); (Y.Z.); (R.M.H.)
| | - Bedros Taslakian
- Division of Vascular Interventional Radiology, Department of Radiology, NYU Grossman School of Medicine, New York, NY 10016, USA; (C.Z.); (C.L.); (Y.Z.); (R.M.H.)
- Correspondence:
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20
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Costache RS, Dragomirică AS, Dumitraș EA, Mariana J, Căruntu A, Popescu A, Costache DO. Portal vein thrombosis: A concise review (Review). Exp Ther Med 2021; 22:759. [PMID: 34035856 DOI: 10.3892/etm.2021.10191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/19/2021] [Indexed: 12/14/2022] Open
Abstract
Portal vein thrombosis (PVT) is a frequent complication in cirrhotic patients, but it may also exist as a basic vascular condition even without any liver damage. Local and systemic factors play a significant role in the pathogenesis of PVT; yet, in practice, more than one factor may be identified. PVT can be considered a result of liver fibrosis and hepatic insufficiency. The JAK2 mutation has been accepted as a factor producing PVT. In general, the anticoagulants are recommended but this therapy should be used carefully in treating patients that associate coagulopathy or thrombocytopenia and esophageal varices. Acute PVT without bowel infarction has a good prognosis. In liver cirrhosis, the mortality due to hemorrhage is higher than in chronic PVT. Therefore, for the patients with PVT, the survival rate is decreased by 55% in two years, due to hepatic insufficiency. Regarding the treatment, LMWH (low molecular weight heparine) is the most utilized in patients with cirrhosis, non-malignancies, infections, or those who are awaiting a liver transplant. DOACs (direct-acting oral anticoagulants) may be used in the rest of the medical conditions, being safe and equal to LMWH.
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Affiliation(s)
- Raluca S Costache
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania.,5th Clinical Department, Gastroenterology and Internal Medicine Discipline, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Andreea S Dragomirică
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania
| | - Elena A Dumitraș
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania
| | - Jinga Mariana
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania.,5th Clinical Department, Gastroenterology and Internal Medicine Discipline, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ana Căruntu
- Department of Maxillofacial Surgery, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania
| | - Andrada Popescu
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania.,5th Clinical Department, Gastroenterology and Internal Medicine Discipline, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Daniel O Costache
- Department of Research, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania
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21
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Safety and Efficacy of Anticoagulation in Patients with Cirrhosis: A Meta-Analysis. Can J Gastroenterol Hepatol 2021; 2021:8859602. [PMID: 34007837 PMCID: PMC8102101 DOI: 10.1155/2021/8859602] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 01/06/2021] [Accepted: 02/08/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND AIMS Portal vein thrombosis is a serious adverse event that occurs during liver cirrhosis. We performed a meta-analysis to evaluate the safety and efficacy of anticoagulant therapy and prophylactic anticoagulant therapy in cirrhosis patients with (/without) portal vein thrombosis. METHODS Eligible comparative studies were identified by searching the following electronic databases: PubMed, Embase, Cochrane Library, Web of Science, and CNKI. A meta-analysis was performed to calculate odds ratios and 95% confidence intervals using fixed-effects models. Recanalization and thrombus progression were defined as the primary outcomes. Secondary outcomes included adverse events and death mortality. RESULTS A total of 3479 patients were included in this analysis. Compared with the control group, the recanalization rate in the anticoagulant therapy group was increased (P < 0.00001) in patients with cirrhosis and portal vein thrombosis without increasing adverse events. Multiple use of enoxaparin in small doses is safer than single large doses (P=0.004). Direct oral anticoagulants are more effective (P < 0.00001) and safer than traditional anticoagulants. Prophylactic anticoagulant therapy can effectively prevent portal vein thrombosis formation (P < 0.00001). CONCLUSIONS Anticoagulation therapy can treat or prevent portal vein thrombosis in patients with liver cirrhosis and is a relatively safe treatment.
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Jain AK, Anand R, Lerret S, Yanni G, Chen JY, Mohammad S, Doyle M, Telega G, Horslen S. Outcomes following liver transplantation in young infants: Data from the SPLIT registry. Am J Transplant 2021; 21:1113-1127. [PMID: 32767649 PMCID: PMC7867666 DOI: 10.1111/ajt.16236] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 02/06/2023]
Abstract
Liver transplantation (LT) in young patients is being performed with greater frequency. We hypothesized that objective analysis of pre-, intra-, and postoperative events would help understand contributors to successful outcomes and guide transplant decision processes. We queried SPLIT registry for pediatric transplants between 2011 and 2018. Outcomes were compared for age groups: 0-<3, 3-<6, 6-<12 months, and 1-<3 years (Groups A, B, C, D respectively) and by weight categories: <5, 5-10, >10 kg; 1033 patients were available for analysis. Cholestatic disease and fulminant failure were highest in group A and those <5 kg; and biliary atresia in group C (72.8%). Group A had significantly higher life support dependence (34.6%; P < .001), listing as United Network for Organ Sharing status 1a/1b (70.4%; P < .001), and shortest wait times (P < .001). The median (interquartile range) for international normalized ratio and bilirubin were highest in group A (3.0 [2.1-3.9] and 16.7 [6.8-29.7] mg/dL) and those <5 kg (2.6 [1.8-3.4] and 13.5 [3.0-28.4] mg/dL). A pediatric end -stage liver disease score ≥40, postoperative hospital stays, rejection, and nonanastomotic biliary strictures were highest in group A with lowest survival at 93.1%. Infants 0 to <3 months and those <5 kg need more intensive care with lower survival and higher complications. Importantly, potential LT before reaching status 1a/1b and aggressive postoperative management may positively influence their outcomes.
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Affiliation(s)
- Ajay K. Jain
- Saint Louis University, Saint Louis, Missouri, USA
| | | | - Stacee Lerret
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - George Yanni
- Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, California, USA
| | | | - Saeed Mohammad
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Majella Doyle
- Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Greg Telega
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Simon Horslen
- Liver and Small Bowel Transplantation, Seattle Children’s Hospital, Seattle, Washington, USA
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Abstract
Portal vein thrombosis (PVT) is one of the common complications of liver cirrhosis, which can further increase portal vein pressure and aggravate liver function decompensation. However, due to the insidious onset and atypical symptoms, the importance of PVT has been neglected in clinical work for quite a long time. With the development of clinical diagnostic technology, the detection rate of PVT has increased year by year. At present, the well-established treatment methods for PVT include anticoagulant therapy, interventional therapy, and surgical treatment. However, the optimal choice for PVT treatment remains unclear. In this paper, we briefly review the recent progress in the diagnosis and treatment of PVT in order to provide a theoretical reference for the refined clinical management of patients with PVT.
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Affiliation(s)
- Wen-Yue Wu
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei 237000, Anhui Province, China
| | - De-Run Kong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Hefei 237000, Anhui Province, China
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24
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Violi F, Loffredo L, Pastori D. Anticoagulation in patients with advanced liver disease: an open issue. Intern Emerg Med 2021; 16:61-71. [PMID: 33073317 DOI: 10.1007/s11739-020-02526-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/30/2020] [Indexed: 12/14/2022]
Abstract
Liver disease has been long considered as a risk factor for bleeding for the presence of prolongation of global tests of clotting activation and low platelet count. For this reason, the use of anticoagulants in patients with liver disease and an indication to anticoagulation, such as atrial fibrillation of venous thrombosis, has been poorly considered. Furthermore, recent studies underscored the fact that patients with chronic liver disease may experience thrombosis in portal as well as systemic circulation and treatment with anticoagulants should be considered. The introduction of direct oral anticoagulants has increased therapeutic options for thromboprophylaxis; however, evidence on their safety and efficacy in specific populations, such as patients with liver disease, is still scarce and needs further investigation. Thus, atrial fibrillation patients with coexistent liver disease have been excluded from clinical trials with direct oral anticoagulants. Here, we provide an overview on mechanisms of thrombosis in patients with advanced chronic liver disease and a summary of evidence on the use of oral anticoagulants in patients with liver disease and portal vein thrombosis or atrial fibrillation.
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Affiliation(s)
- Francesco Violi
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, I Clinica Medica, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
- Mediterranea Cardiocentro, via Orazio 2, 80122, Naples, Italy.
| | - Lorenzo Loffredo
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, I Clinica Medica, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, I Clinica Medica, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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25
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Li M, Luo J, Chen J, Wu C, Pan T, Huang M, Jiang Z. Application of percutaneous transluminal sharp recanalization in transjugular intrahepatic portosystemic shunt for patients with chronic portal vein occlusion. Diagn Interv Radiol 2020; 27:257-262. [PMID: 33044172 DOI: 10.5152/dir.2020.20461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE We aimed to evaluate the feasibility and safety of a modified technique for portal vein recanalization, percutaneous transluminal sharp recanalization (PTSR), when performing transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of chronic portal vein occlusion (CPVO) and portal hypertension. METHODS Nine consecutive patients with CPVO and portal hypertension had undergone TIPS and PTSR procedure after failing in conventional percutaneous catheterization from March 2017 to July 2019. Technical success rates, effectiveness, and complications were evaluated. Follow-up of patients' clinical outcomes and shunt patency were performed periodically. Primary and secondary shunt patency were analyzed by Kaplan-Meier method. RESULTS The occluded portal veins were successfully recanalized after failing in conventional percutaneous catheterization, and TIPS procedures were completed in all 9 patients. Two patients suffered from procedure-related complications. A portosystemic pressure gradient <12 mmHg, or a percent reduction of 25% to 50% of baseline, was achieved in all 9 patients after TIPS. During the median follow-up period of 28 months (range, 9-36 months), 1 patient experienced recurrent ascites and the other 8 patients remained asymptomatic. The cumulative rates of primary and secondary shunt patency were 66.67% and 100%, respectively, at 2 years. CONCLUSION As a supplementary method, PTSR is a feasible and safe method for portal vein recanalization when performing TIPS for patients with CPVO and portal hypertension.
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Affiliation(s)
- Mingan Li
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Junyang Luo
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Junwei Chen
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chun Wu
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tao Pan
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Mingsheng Huang
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zaibo Jiang
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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26
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Moik F, Pabinger I, Ay C. How I treat cancer-associated thrombosis. ESMO Open 2020; 5:e000610. [PMID: 31958288 PMCID: PMC7003382 DOI: 10.1136/esmoopen-2019-000610] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/09/2019] [Accepted: 11/15/2019] [Indexed: 12/21/2022] Open
Abstract
Patients with cancer are at an increased risk of symptomatic venous thromboembolism (VTE). In addition, an increasing number of patients with incidental thromboembolic events have been recorded in clinical practice. Therapeutic anticoagulation is crucial to prevent thrombus progression and reduce risk of recurrence; however, this comes at the price of an increased bleeding risk, which necessitates a personalised approach to choose the most appropriate type of therapy. Over the last decade, low-molecular-weight heparin has been the preferred anticoagulant agent for patients with cancer-associated thrombosis due to better efficacy and similar safety profile compared with vitamin K antagonists. While direct oral anticoagulants (DOAC) have emerged as new option for treatment of VTE in a general population, only limited data have been available specifically for patients with cancer until recently. Randomised, controlled trials have now been published, establishing DOAC as an alternative for the treatment of cancer-associated thrombosis. However, the improvement in the therapeutic armamentarium is accompanied by a number of special considerations. For instance, risk of bleeding is elevated in patients with cancer-associated VTE receiving DOAC, especially in certain tumour types (eg, gastrointestinal), and no guidance exists regarding their use in patients with severe thrombocytopaenia. Furthermore, DOAC are prone to certain drug-drug interactions and their effect might be altered due to nausea and vomiting in patients receiving chemotherapy. Here, we provide guidance on how to treat cancer-associated VTE and how new evidence from randomised controlled trials can be implemented in clinical practice. There are still clinical scenarios where robust evidence is lacking and treatment recommendations are based on extrapolations from other populations or expert opinion only. Therefore, additional research in special subpopulations is needed to optimise management of patients in challenging clinical scenarios.
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Affiliation(s)
- Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria; I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
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