1
|
Xu Z, Pappas C, Sarofim M, Wijayawardana R, Morris D. Diagnostic conundrum: massive portal vein pathology in a young patient - benign or malignant? ANZ J Surg 2024; 94:954-955. [PMID: 38450578 DOI: 10.1111/ans.18887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Zhengchao Xu
- St George Hospital, Department of Surgery and Peritonectomy Unit, St George Hospital, Sydney, New South Wales, Australia
- Department of Surgery, University of New South Wales, School of Medicine, Sydney, New South Wales, Australia
| | - Christian Pappas
- St George Hospital, Department of Surgery and Peritonectomy Unit, St George Hospital, Sydney, New South Wales, Australia
- Department of Surgery, University of New South Wales, School of Medicine, Sydney, New South Wales, Australia
| | - Mina Sarofim
- St George Hospital, Department of Surgery and Peritonectomy Unit, St George Hospital, Sydney, New South Wales, Australia
- Department of Surgery, University of New South Wales, School of Medicine, Sydney, New South Wales, Australia
| | - Ruwanthi Wijayawardana
- St George Hospital, Department of Surgery and Peritonectomy Unit, St George Hospital, Sydney, New South Wales, Australia
- Department of Surgery, University of New South Wales, School of Medicine, Sydney, New South Wales, Australia
| | - David Morris
- St George Hospital, Department of Surgery and Peritonectomy Unit, St George Hospital, Sydney, New South Wales, Australia
- Department of Surgery, University of New South Wales, School of Medicine, Sydney, New South Wales, Australia
| |
Collapse
|
2
|
Capinha F, Ferreira CN. Management of Nonmalignant Portal Vein Thrombosis in Cirrhosis. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2024; 31:77-88. [PMID: 38572442 PMCID: PMC10987170 DOI: 10.1159/000533161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 07/10/2023] [Indexed: 04/05/2024]
Abstract
Nonmalignant portal vein thrombosis (PVT) is a common complication of cirrhosis especially at the stage of decompensations. The diagnosis of PVT in cirrhosis is often incidental and it may be detected during routine semestral abdominal ultrasound with Doppler during screening for hepatocellular carcinoma or during hospitalization for decompensated cirrhosis. After detection of PVT on abdominal ultrasound, it is important to evaluate patients with cross-sectional imaging to determine the age of thrombus, whether acute or chronic, the extent and degree of luminal occlusion of the portal vein, and to rule out hepatocellular carcinoma or other underlying malignancy. Factors influencing management include the degree and extent of luminal occlusion of PVT, potential listing for liver transplantation, and portal hypertension (PHT) complications such as variceal hemorrhage and refractory ascites, severity of thrombocytopenia, and other comorbidities including chronic kidney disease. Anticoagulation is the most common therapeutic option and it is specially indicated in patients who are candidates for liver transplantation. Interventional procedures including transjugular intrahepatic portosystemic shunt (TIPS) placement and mechanical thrombectomy may be used on a case-by-case basis in patients with contraindications or adverse events related to anticoagulation, who develop worsening PVT while on anticoagulant therapy, or have chronic PVT and PHT complications that are not manageable medically or endoscopically.
Collapse
Affiliation(s)
- Francisco Capinha
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina de Lisboa, Universidade de Lisboa, Lisbon, Portugal
| |
Collapse
|
3
|
Tsuchida Y, Tsubata Y, Nozawa R, Maruyama S, Ikarashi K, Saito N, Morioka T, Kamura T, Shimada H, Narita I. Fatal acute portal vein thrombosis associated with hepatic cysts in a patient with autosomal dominant polycystic kidney disease. CEN Case Rep 2024; 13:32-36. [PMID: 37162720 PMCID: PMC10834907 DOI: 10.1007/s13730-023-00795-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/30/2023] [Indexed: 05/11/2023] Open
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) often involves polycystic liver disease (PLD). In severe cases, PLD can develop various complications. However, fatal acute portal vein thrombosis (APVT) associated with PLD has not been reported. A 64-year-old male reported mild consciousness disorder. He had been under maintenance hemodialysis for end-stage renal disease due to ADPKD with PLD. Because of recurring hepatic cyst infections, he had sustained high levels of C-reactive protein. Regarding the mild consciousness disorder, a diagnosis of hepatic encephalopathy was made based on an elevation of serum ammonia without any other abnormal liver function tests. Several days after his admission, hepatobiliary enzymes elevated, and acute liver failure progressed. Enhanced abdominal computed tomography suggested the possibility of complete occlusion of the portal vein by a thrombus. Based on an absence of obvious portosystemic collaterals, a diagnosis of APVT was made. The patient died 19 days after admission. Patients with PLD with repeated cystic infections have been seen to develop liver failure, and APVT formation may be one cause of the rapid progression of fatal liver failure. In conclusion, this is the first paper to report on the involvement of APVT in patients with PLD.
Collapse
Affiliation(s)
- Yohei Tsuchida
- Department of Nephrology, Shinrakuen Hospital, 3-3-11 Shindori-Minami, Nishi-Ku, Niigata, 950-2087, Japan.
| | - Yutaka Tsubata
- Department of Nephrology, Shinrakuen Hospital, 3-3-11 Shindori-Minami, Nishi-Ku, Niigata, 950-2087, Japan
| | - Ryosuke Nozawa
- Department of Gastroenterology, Shinrakuen Hospital, Niigata, Japan
| | - Shuntaro Maruyama
- Department of Nephrology, Shinrakuen Hospital, 3-3-11 Shindori-Minami, Nishi-Ku, Niigata, 950-2087, Japan
| | - Kouzo Ikarashi
- Department of Nephrology, Shinrakuen Hospital, 3-3-11 Shindori-Minami, Nishi-Ku, Niigata, 950-2087, Japan
| | - Noriko Saito
- Department of Nephrology, Shinrakuen Hospital, 3-3-11 Shindori-Minami, Nishi-Ku, Niigata, 950-2087, Japan
| | - Tetsuo Morioka
- Department of Nephrology, Shinrakuen Hospital, 3-3-11 Shindori-Minami, Nishi-Ku, Niigata, 950-2087, Japan
| | - Takeshi Kamura
- Department of Diagnostic Radiology, Shinrakuen Hospital, Niigata, Japan
| | - Hisaki Shimada
- Department of Nephrology, Shinrakuen Hospital, 3-3-11 Shindori-Minami, Nishi-Ku, Niigata, 950-2087, Japan
| | - Ichiei Narita
- Divisions of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| |
Collapse
|
4
|
Tang K, Weinberg EM. Direct oral anticoagulants in the treatment of portal vein thrombosis in patients with portal hypertension. Clin Liver Dis (Hoboken) 2023; 22:37-41. [PMID: 37663556 PMCID: PMC10473309 DOI: 10.1097/cld.0000000000000063] [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: 09/05/2022] [Accepted: 12/23/2022] [Indexed: 09/05/2023] Open
Affiliation(s)
- Kevin Tang
- Department of Internal Medicine, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ethan M. Weinberg
- Department of Gastroenterology & Hepatology, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
5
|
Proskuriakova E, Jasaraj RB, Shrestha DB, Reddy VK, Khosla P. Acute Portal Vein Thrombosis as an Initial Presentation of Protein C Deficiency: A Case Report. Cureus 2023; 15:e40407. [PMID: 37456450 PMCID: PMC10347885 DOI: 10.7759/cureus.40407] [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: 04/30/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
Protein C (PC) is an essential vitamin K-dependent protein that regulates thrombosis and hemostasis in the body. A mutation in the PROC gene on chromosome 2q14.3 results in PC deficiency. The clinical presentation of PC deficiency can vary, ranging from a single vein thrombosis to disseminated intravascular coagulation, purpura fulminans, or even life-threatening complications such as sepsis. Here, we present a case of a 37-year-old female who was found to have acute portal vein thrombosis as an initial presentation of PC deficiency. She presented to the hospital with acute onset of abdominal pain associated with nausea, blood-streaked emesis, and bloody bowel movement.
Collapse
Affiliation(s)
| | | | | | | | - Pam Khosla
- Hematology and Oncology, Mount Sinai Hospital, Chicago, USA
| |
Collapse
|
6
|
Efficacy and safety of direct oral anticoagulants versus vitamin K antagonist for portal vein thrombosis in cirrhosis: A systematic review and meta-analysis. Dig Liver Dis 2022; 54:56-62. [PMID: 34393072 DOI: 10.1016/j.dld.2021.07.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/19/2021] [Accepted: 07/24/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND AIM Portal vein thrombosis (PVT) is associated with a higher risk of liver-related complications. Recent guidelines recommend direct-acting anticoagulants (DOAC) in patients with cirrhosis and non-tumoral PVT. However, data on the efficacy and safety of DOAC in these patients remain limited. We aim to investigate the efficacy and safety of DOAC compared to vitamin K antagonists (VKA) to treat non-tumoral PVT in patients with cirrhosis. METHODS We performed a systematic search of six electronic databases using MeSH term and free text. We selected all studies comparing the use of DOACs with vitamin K antagonist to treat PVT in cirrhosis. The primary outcome was PVT recanalization. Secondary outcomes were and PVT progression, major bleeding, variceal bleeding and death. RESULTS From 944 citations, we included 552 subjects from a total of 11 studies (10 observational and 1 randomized trial) that fulfilled the inclusion criteria. We found that DOAC were associated with a higher pooled rate of PVT recanalization (RR = 1.67, 95%CI: 1.02, 2.74, I2 = 79%) and lower pooled risk of PVT progression (RR = 0.14, 95%CI: 0.03-0.57, I2 = 0%). The pooled risk of major bleeding (RR = 0.29, 95%CI: 0.08-1.01, I2 = 0%), variceal bleeding (RR = 1.29, 95%CI: 0.64-2.59, I2 = 0%) and death (RR = 0.31, 95%CI: 0.01-9.578, I2 = 80%) was similar between DOAC and VKA. CONCLUSION For the treatment of PVT in patients with cirrhosis, the bleeding risk was comparable between DOAC and VKA. However, DOAC were associated with a higher pooled rate of PVT recanalization. Dedicated randomized studies are needed to confirm these findings.
Collapse
|
7
|
Zheng SM, Lin N, Tang SH, Yang JY, Wang HQ, Luo SL, Zhang Y, Mu D. Isolated hepatic tuberculosis associated with portal vein thrombosis and hepatitis B virus coinfection: A case report and review of the literature. World J Clin Cases 2021; 9:9310-9319. [PMID: 34786418 PMCID: PMC8567534 DOI: 10.12998/wjcc.v9.i30.9310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/09/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND While tuberculosis (TB) itself is a common disease, isolated TB of the liver is a rare entity. Tubercular involvement of the liver is more commonly a part of a disseminated disease of the hepatic parenchyma. In contrast, isolated hepatic TB spread through the portal vein from the gastrointestinal tract is seldom encountered in clinical practice, with only a few sporadic cases and short series available in the current literature. Vascular complications, such as portal vein thrombosis (PVT), have rarely been reported previously.
CASE SUMMARY A 22-year-old man was hospitalized with complaints of a 3-mo history of fever and weight loss of approximately 10 kg. He had a 10-year hepatitis B virus (HBV) infection in his medical history. Contrast-enhanced computed tomography (CECT) confirmed hepatosplenomegaly, with hypodensity of the right lobe of the liver and 2.1 cm thrombosis of the right branch of the portal vein. A liver biopsy showed epithelioid granulomas with a background of caseating necrosis. Ziehl-Nelson staining showed acid-fast bacilli within the granulomas. The patient was diagnosed with isolated hepatic TB with PVT. Anti-TB therapy (ATT), including isoniazid, rifapentine, ethambutol, and pyrazinamide, was administered. Along with ATT, the patient was treated with entecavir as an antiviral medication against HBV and dabigatran as an anticoagulant. He remained asymptomatic, and follow-up sonography of the abdomen at 4 mo showed complete resolution of the PVT.
CONCLUSION Upon diagnosis of hepatic TB associated with PVT and HBV coinfection, ATT and anticoagulants should be initiated to prevent subsequent portal hypertension. Antiviral therapy against HBV should also be administered to prevent severe hepatic injury.
Collapse
Affiliation(s)
- Shu-Mei Zheng
- Department of Gastroenterology and Hepatology, The General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Ning Lin
- Department of Clinical Nutrition, The General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Shan-Hong Tang
- Department of Gastroenterology and Hepatology, The General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Jia-Yi Yang
- School of Medical Imaging, Nanjing Medical University, Nanjing 211166, Jiangsu Province, China
| | - Hai-Qiong Wang
- Department of Gastroenterology and Hepatology, The General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Shu-Lan Luo
- Department of Gastroenterology and Hepatology, The General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Yong Zhang
- Department of Gastroenterology and Hepatology, The General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Dong Mu
- Department of Gastroenterology and Hepatology, The General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| |
Collapse
|
8
|
Gupta S, Hidalgo J, Singh B, Iyer A, Yang Y, Short A, Singh S, Bhatt H, Gupta S. Usage of Direct Acting Oral Anticoagulants in Cirrhotic and Non-Cirrhotic Portal Vein Thrombosis: A Systematic Review. Cureus 2021; 13:e16922. [PMID: 34367844 PMCID: PMC8342267 DOI: 10.7759/cureus.16922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 12/15/2022] Open
Abstract
Thrombosis of the portal vein (PVT) is generally seen in the setting of liver cirrhosis and to a lesser extent in the absence of cirrhosis. There is no clear guidance in relation to approaching treatment with anticoagulation in this condition. The professional societies and guidelines recommend treatment with traditional anticoagulation like low-molecular-weight heparin and vitamin-K antagonists in patients presenting with acute portal vein thrombosis. There is no clarity in relation to treatment in the setting of chronic PVT and in patients with cirrhosis. Also, the role of direct-acting oral anticoagulants (DOACs) that are becoming a preferred choice for anticoagulation for various other indications is not clear in the case of PVT. There are a very few studies in the medical literature that have investigated the role of DOACs in patients with PVT in different settings. Thus, we performed a systematic review of the literature to study the use of DOACs in PVT in patients with and without cirrhosis. The results of the available studies show that DOACS appears to be a promising choice for the treatment of patients with PVT. The availability of more data in the future along with better availability of the approved reversal agents for various DOACs is expected to make DOACS a preferred choice for the clinicians to treat patients with PVT.
Collapse
Affiliation(s)
- Sachin Gupta
- Hospital Medicine, Tower Health Reading Hospital, West Reading, USA
| | - Jessica Hidalgo
- Internal Medicine, San Francisco de Quito University, Quito, ECU
| | - Balraj Singh
- Hematology/Oncology, Saint Joseph's University Medical Center, Paterson, USA
| | - Aditya Iyer
- Internal Medicine, Washington Hospital Center, Washington DC, USA
| | - Yang Yang
- Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Alexandra Short
- Library Services, Tower Health Reading Hospital, West Reading, USA
| | - Sandeep Singh
- Internal Medicine, Indiana University School of Medicine, South Bend, USA
| | - Harshil Bhatt
- Internal Medicine, Indiana University School of Medicine, South Bend, USA
- Internal Medicine, Goshen Hospital, Goshen, USA
| | - Sorab Gupta
- Oncology, Bronx Care Health System, New York, USA
| |
Collapse
|
9
|
Abstract
Portal vein thrombosis (PVT) is a splanchnic vascular disorder characterised by a recent or chronic thrombotic occlusion of the portal venous system. Its aetiology is miscellaneous, and its management is demanding since PVT can play a critical role as far as morbidity and mortality are concerned. Indeed, PVT can develop as a complication of portal hypertension (PH), in association or not with advanced chronic liver disease, and aggravate its clinical consequences such as variceal bleeding and ascites. Furthermore, a diagnosis of PVT in a non-cirrhotic context can potentially reveal a previously unknown hypercoagulable condition, requiring further diagnostic steps and specific treatment in addition to anticoagulation. In addition to established therapeutic approaches, new strategies, including newer pharmacological treatments and interdisciplinary invasive procedures, gain more attention and have been increasingly introduced into clinical practice. This review aims at discussing the current knowledge in terms of treatment options for PVT.
Collapse
|
10
|
Guyot A, Lequeu JB, Dransart-Rayé O, Chevallier O, Nguyen M, Charles PE, Mouillot T, Manfredi S, Degand T. [Management of acute pancreatitis. A literature review]. Rev Med Interne 2021; 42:625-632. [PMID: 33676780 DOI: 10.1016/j.revmed.2021.01.003] [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: 08/08/2020] [Revised: 12/02/2020] [Accepted: 01/09/2021] [Indexed: 12/07/2022]
Abstract
The management of acute pancreatitis is now fairly codified, with specific recommendations developed by expert groups. These recommendations deal in particular with the minimum initial assessment, recognized severity scores, initial medical management with hyperhydration, preventive anticoagulation, early refeeding, delays in imaging and management of complications. In this work, we have tried to bring together the various recommendations, articles and studies dealing with this subject, based more particularly on European recommendations, in order to guide the management of acute pancreatitis in current practice.
Collapse
Affiliation(s)
- A Guyot
- Service d'hépato-gastro-entérologie, CHU de Dijon F.-Mitterrand Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France.
| | - J B Lequeu
- Chirurgie viscérale, digestive et endocrinienne, CHU de Dijon, Dijon, France.
| | - O Dransart-Rayé
- Département d'anesthésie réanimation, CHU de Dijon, Dijon, France.
| | - O Chevallier
- Département de radiologie diagnostique et thérapeutique, CHU de Dijon, Dijon, France.
| | - M Nguyen
- Département d'anesthésie réanimation, CHU de Dijon, Dijon, France.
| | - P E Charles
- Médecine intensive réanimation, CHU de Dijon, Dijon, France.
| | - T Mouillot
- Service d'hépato-gastro-entérologie, CHU de Dijon F.-Mitterrand Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France.
| | - S Manfredi
- Service d'hépato-gastro-entérologie, CHU de Dijon F.-Mitterrand Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France.
| | - T Degand
- Service d'hépato-gastro-entérologie, CHU de Dijon F.-Mitterrand Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France.
| |
Collapse
|
11
|
Abstract
Die Pfortaderthrombose ist eine seltene Erkrankung, die eine Thrombose im Zustromgebiet der Pfortader in die Leber beschreibt bzw. in der Leber selbst in den entsprechenden Pfortaderästen lokalisiert ist. Oftmals liegt bereits eine chronische Lebererkrankung bzw. ein Malignom der Leber selbst oder unmittelbar benachbart liegender Organe vor; die Pfortaderthrombose kann aber auch bei Patienten auftreten, die keine entsprechende Vorerkrankung haben. Bei jeder neu diagnostizierten Pfortaderthrombose gilt es zu entscheiden, ob unmittelbar oder im Verlauf eine radiologisch-interventionelle Rekanalisation vorgenommen wird oder ein rein konservativer Therapieversuch mit Antikoagulanzien erfolgt. Aber auch chirurgische Verfahren, wie eine Shuntanlage oder die Notwendigkeit einer Lebertransplantation, müssen hierbei berücksichtigt werden. Für diesen Therapiealgorithmus ist die Kontaktaufnahme mit einem entsprechenden Zentrum sinnvoll. Die Therapieentscheidung muss die Ursache der Pfortaderthrombose und die Begleiterkrankungen adäquat berücksichtigen.
Collapse
|
12
|
Northup PG, Garcia-Pagan JC, Garcia-Tsao G, Intagliata NM, Superina RA, Roberts LN, Lisman T, Valla DC. Vascular Liver Disorders, Portal Vein Thrombosis, and Procedural Bleeding in Patients With Liver Disease: 2020 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 73:366-413. [PMID: 33219529 DOI: 10.1002/hep.31646] [Citation(s) in RCA: 281] [Impact Index Per Article: 93.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Patrick G Northup
- Division of Gastroenterology and Hepatology, Center for the Study of Hemostasis in Liver Disease, University of Virginia, Charlottesville, VA
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver), Barcelona, Spain
| | - Guadalupe Garcia-Tsao
- Department of Internal Medicine, Section of Digestive Diseases, Yale University, New Haven, CT.,Veterans Administration Healthcare System, West Haven, CT
| | - Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, Center for the Study of Hemostasis in Liver Disease, University of Virginia, Charlottesville, VA
| | - Riccardo A Superina
- Department of Transplant Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Surgical Research Laboratory, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Dominique C Valla
- Hepatology Service, Hospital Beaujon, Clichy, France.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver), Barcelona, Spain
| |
Collapse
|
13
|
Venous thrombosis of the liver: current and emerging concepts in management. Transl Res 2020; 225:54-69. [PMID: 32407789 DOI: 10.1016/j.trsl.2020.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/11/2020] [Accepted: 04/16/2020] [Indexed: 02/08/2023]
Abstract
Venous thrombosis within the hepatic vasculature is associated with a distinct array of risk factors, characteristics, and potential complication. As such, it entails unique management considerations and strategies relative to the more common categories of venous thromboembolic disease. Although broadly divided into thrombosis of the afferent vasculature (the portal venous system) and efferent vasculature (the hepatic venous system), presentations and management strategies within these groupings are heterogeneous. Management decisions are influenced by a variety of factors including the chronicity, extent, and etiology of thrombosis. In this review we examine both portal vein thrombosis and hepatic vein thrombosis (and the associated Budd-Chiari Syndrome). We consider those factors which most impact presentation and most influence treatment. In so doing, we see how the particulars of specific cases introduce nuance into clinical decisions. At the same time we attempt to organize our understanding of such cases to help facilitate a more systematic approach. Critically, we must recognize that although increasing evidence is emerging to help guide our management strategies, the available data remain limited and largely retrospective. Indeed, current paradigms are based largely on observational experiences and expert consensus. As new and more rigorous studies emerge, treatment strategies are likely to be continually refined, and paradigm shifts are sure to occur.
Collapse
|
14
|
Heurgué A, Habes D, Brugel M, Franchi-Abella S, Condat B, Valla D, Hillaire S, Debray D, Hernandez-Gea V, Dutheil D, Plessier A, Bureau C, Payancé A. Recent (non-cirrhotic) extrahepatic portal vein obstruction. Clin Res Hepatol Gastroenterol 2020; 44:460-465. [PMID: 32448586 DOI: 10.1016/j.clinre.2020.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Alexandra Heurgué
- Department of Gastroenterology and Hepatology, Robert Debré Hospital, University Hospital of Reims, avenue du Général-Koening, 51092 Reims cedex, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France.
| | - Dalila Habes
- Department of Pediatric Hepatology, Bicêtre Hospital, AP-HP, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Mathias Brugel
- Department of Gastroenterology and Hepatology, Robert Debré Hospital, University Hospital of Reims, avenue du Général-Koening, 51092 Reims cedex, France
| | - Stéphanie Franchi-Abella
- Department of Pediatric Radiology, Bicêtre Hospital, AP-HP, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Bertrand Condat
- Department of Gastroenterology, Hospital of French Polynesia, BP 1640 Papeete, 98 713 Tahiti, French Polynesia; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Dominique Valla
- Department of Hepatology and reference center of vascular liver diseases, Beaujon Hospital, AP-HP, 100, boulevard du Général-Leclerc, 92118 Clichy, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Sophie Hillaire
- Department of Internal Medicine, Foch Hospital, 40, rue Worth, 92150 Suresnes, France
| | - Dominique Debray
- Department of Pediatric Hepatology, Hôpital Necker - enfants maladies, AP-HP, 149, rue de Sèvres, 75743 Paris cedex 15, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona. Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd). Health Care Provider of the European Reference Network onRare Liver Disorders (ERN-Liver), Spain
| | - Danielle Dutheil
- Department of Hepatology, Association of patients with vascular liver diseases (AMVF), Beaujon Hospital, 100, boulevard du Général-Leclerc, 92118 Clichy, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Aurélie Plessier
- Department of Hepatology and reference center of vascular liver diseases, Beaujon Hospital, AP-HP, 100, boulevard du Général-Leclerc, 92118 Clichy, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France; Reference center of vascular liver diseases, European Reference Network (ERN) "Rare-Liver", Beaujon Hospital, Clichy, France
| | - Christophe Bureau
- Department of Gastroenterology and Hepatology, Rangueil Hospital, University Hospital of Toulouse, 1, avenue du Professeur-Jean-Poulhès, 31400 Toulouse, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Audrey Payancé
- Department of Hepatology and reference center of vascular liver diseases, Beaujon Hospital, AP-HP, 100, boulevard du Général-Leclerc, 92118 Clichy, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| |
Collapse
|
15
|
Treatment of unusual thrombotic manifestations. Blood 2020; 135:326-334. [PMID: 31917405 DOI: 10.1182/blood.2019000918] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/28/2019] [Indexed: 12/21/2022] Open
Abstract
Venous thrombosis rarely occurs at unusual sites such as cerebral, splanchnic, upper-extremity, renal, ovarian, or retinal veins. Clinical features, symptoms, and risk factors of rare thrombotic manifestations are heterogeneous and in large part differ from those typical of the commonest manifestations of venous thrombosis at the lower extremities. The therapeutic approach also varies widely according to the affected site, whether cerebral, abdominal, or extraabdominal. To date, anticoagulant therapy for thrombosis at unusual sites is generally accepted, but the optimal therapeutic approach remains challenging. This review is focused on the treatment of unusual thrombotic manifestations as reported in the most recent guidelines and according to the updated scientific literature.
Collapse
|
16
|
Abstract
Pylephlebitis is a rare condition that is characterized by an infected thrombus of the portal vein system and was traditionally associated with a high mortality rate prior to the introduction of antibiotics. This report details a 77-year-old Chinese male found to have a splenic vein thrombosis, Parvimonas micra bacteremia, and a polymicrobial splenic abscess. The patient was treated with abscess drainage and a 6 week course of intravenous antibiotics, and a direct oral anticoagulant, apixaban 2.5 mg twice daily. To our knowledge, this is the second documented case of pylephlebitis treated with apixaban. Here, we summarize our experience treating this case of pylephlebitis and briefly report on the existing body of literature.
Collapse
Affiliation(s)
- Graham R Hale
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Leon Alan Sakkal
- Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA
| | - Taki Galanis
- Jefferson Vascular Center, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| |
Collapse
|
17
|
Hernández-Gea V, De Gottardi A, Leebeek FWG, Rautou PE, Salem R, Garcia-Pagan JC. Current knowledge in pathophysiology and management of Budd-Chiari syndrome and non-cirrhotic non-tumoral splanchnic vein thrombosis. J Hepatol 2019; 71:175-199. [PMID: 30822449 DOI: 10.1016/j.jhep.2019.02.015] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 12/11/2022]
Abstract
Budd-Chiari syndrome and non-cirrhotic non-tumoral portal vein thrombosis are 2 rare disorders, with several similarities that are categorized under the term splanchnic vein thrombosis. Both disorders are frequently associated with an underlying prothrombotic disorder. They can cause severe portal hypertension and usually affect young patients, negatively influencing life expectancy when the diagnosis and treatment are not performed at an early stage. Yet, they have specific features that require individual consideration. The current review will focus on the available knowledge on pathophysiology, diagnosis and management of both entities.
Collapse
Affiliation(s)
- Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, European Reference Network for Rare Vascular Liver Diseases, Universitat de Barcelona, Spain
| | - Andrea De Gottardi
- Hepatology, University Clinic of Visceral Medicine and Surgery, Inselspital, and Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France; Inserm, UMR-970, Paris Cardiovascular Research Center, PARCC, Paris, France
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, European Reference Network for Rare Vascular Liver Diseases, Universitat de Barcelona, Spain.
| |
Collapse
|
18
|
Intagliata NM, Caldwell SH, Tripodi A. Diagnosis, Development, and Treatment of Portal Vein Thrombosis in Patients With and Without Cirrhosis. Gastroenterology 2019; 156:1582-1599.e1. [PMID: 30771355 DOI: 10.1053/j.gastro.2019.01.265] [Citation(s) in RCA: 199] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 01/11/2019] [Accepted: 01/21/2019] [Indexed: 02/06/2023]
Abstract
Portal vein thrombosis unrelated to solid malignancy is common in patients with cirrhosis, but less frequently observed in patients without cirrhosis. Prompt diagnosis and management of acute symptomatic portal vein thrombosis are essential. Failure to detect and treat thromboses can result in mesenteric ischemia, chronic cavernous transformation, and complications of portal hypertension. In patients with cirrhosis, development of portal vein thrombosis is often insidious and remains undetected until its incidental detection. Management of portal vein thrombosis in patients with cirrhosis is more controversial. However, there are data to support treatment of specific patients with anticoagulation agents. We review the common and distinct features of portal vein thromboses in patients without liver tumors, with and without cirrhosis.
Collapse
Affiliation(s)
- Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, University of Virginia Medical CenterCharlottesville, Virginia.
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia Medical CenterCharlottesville, Virginia
| | - Armando Tripodi
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
| |
Collapse
|
19
|
Steuber TD, Howard ML, Nisly SA. Direct Oral Anticoagulants in Chronic Liver Disease. Ann Pharmacother 2019; 53:1042-1049. [PMID: 30947523 DOI: 10.1177/1060028019841582] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective: To review the use of direct oral anticoagulants (DOACs) in patients with chronic liver disease (CLD). Data Sources: A MEDLINE literature search was performed from 1964 through February 2019 using the following search terms: cirrhosis, chronic liver disease, direct oral anticoagulant, and the individual DOACs. Study Selection and Data Extraction: All English-language human trials and reports that examined DOACs for treatment or prevention of venous thromboembolic (VTE) events in patients with CLD were included. Data Synthesis: A total of 6 clinical trials examining the use of DOACs in patients with CLD were identified. All DOACs have been utilized in patients with CLD, with the exception of betrixaban, for prevention of stroke in atrial fibrillation or treatment of VTE (except for treatment of pulmonary embolism). The studies primarily evaluated patients with mild to moderate liver disease (Child-Turcotte-Pugh class A and B). The DOACs had similar rates of bleeding compared with traditional anticoagulants. Relevance to Patient Care and Clinical Practice: This review evaluates and summarizes the available evidence on DOACs in the setting of CLD. These agents may be more appealing in this population because monitoring or administration may be difficult with traditional anticoagulants (warfarin or low-molecular-weight heparins). Conclusion: Early data suggest that DOACs may be safe in patients with mild to moderate CLD. Should a DOAC be selected as an alternative to traditional anticoagulants, more frequent monitoring should be used because hepatotoxicity may be a concern. Larger clinical trials are needed to address efficacy outcomes as well as differences among individual DOACs in this population.
Collapse
Affiliation(s)
- Taylor D Steuber
- 1 Auburn University Harrison School of Pharmacy, Huntsville, AL, USA
| | - Meredith L Howard
- 2 University of North Texas System College of Pharmacy, Fort Worth, TX, USA
| | - Sarah A Nisly
- 3 Wingate University School of Pharmacy, Wingate, NC, USA
| |
Collapse
|
20
|
Dal Zotto C, Wieczorek M, Mariottini G, Malagò R, Olivieri O, De Franceschi L. Persistent abdominal pain related to portal vein thrombosis in young adult with sickle cell disease. Am J Hematol 2018; 93:1562-1565. [PMID: 30230563 DOI: 10.1002/ajh.25291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/07/2018] [Accepted: 09/12/2018] [Indexed: 01/16/2023]
Affiliation(s)
- Chiara Dal Zotto
- Department of Medicine; University of Verona and AOUI Verona; Verona Italy
| | - Michele Wieczorek
- Department of Medicine; University of Verona and AOUI Verona; Verona Italy
| | | | - Roberto Malagò
- Department of Diagnostic Imaging; University of Verona and AOUI Verona; Verona Italy
| | - Oliviero Olivieri
- Department of Medicine; University of Verona and AOUI Verona; Verona Italy
| | | |
Collapse
|
21
|
Thachil J. Will direct oral anticoagulants completely replace warfarin? Br J Hosp Med (Lond) 2018; 79:604-605. [PMID: 30418820 DOI: 10.12968/hmed.2018.79.11.604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jecko Thachil
- Consultant, Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester M13 9WL
| |
Collapse
|
22
|
Zhou H, Xuan J, Lin X, Guo Y. Recurrent esophagogastric variceal bleeding due to portal vein thrombosis caused by protein S deficiency. Endosc Int Open 2018; 6:E1283-E1288. [PMID: 30410946 PMCID: PMC6221818 DOI: 10.1055/a-0684-9638] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/30/2018] [Indexed: 12/20/2022] Open
Abstract
Background and study aims Esophagogastric variceal bleeding (EGVB) is common in patients with portal vein thrombosis (PVT). Hereditary deficiencies in natural anticoagulant proteins, such as protein S, might contribute to PVT. However, recurrent EGVB caused by PVT in patients with protein S deficiency is seldom reported. Herein, we present the case of a 38-year-old man with protein S deficiency complicated with PVT. The patient suffered recurrent EGVB for 7 years. He underwent splenectomy plus pericardial revascularization and sequential endoscopic therapy, including one gastric variceal obturation (GVO) procedure and two esophageal variceal ligations (EVL) to eradicate the varices. Rivaroxaban was administrated to reduce risk of thrombotic events. The patient is currently well without rebleeding after 1 year of follow-up. To our knowledge there is no consensus on management of recurrent EGVB on the basis of thrombophilia complicated with PVT. According to our practice, sequential endoscopic therapy combined with anticoagulant appears to be effective and safe.
Collapse
Affiliation(s)
- Haoxiong Zhou
- Department of Gastroenterology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
| | - Jieying Xuan
- Department of Gastroenterology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
| | - Xianyi Lin
- Department of Gastroenterology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
| | - Yunwei Guo
- Department of Gastroenterology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Corresponding author Yunwei Guo, MD, PhD Associate ProfessorDepartment of GastroenterologyThe Third Affiliated Hospital of Sun Yat-Sen UniversityNo. 600 Tianhe RoadTianhe District, Guangzhou 510630, Guangdong ProvinceChina+86-20-85253336
| |
Collapse
|
23
|
Newer Oral Anticoagulants in the Treatment of Acute Portal Vein Thrombosis in Patients with and without Cirrhosis. Int J Hepatol 2018; 2018:8432781. [PMID: 29973997 PMCID: PMC6008786 DOI: 10.1155/2018/8432781] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 04/30/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Newer oral anticoagulants (NOACs) are being utilized increasingly for the treatment of venous thromboembolism (VTE). NOAC use is the standard of care for stroke prophylaxis in nonvalvular atrial fibrillation and treatment of acute VTE involving extremities and pulmonary embolism. In contrast, most guidelines in the literature support the treatment of acute portal vein thrombosis (PVT) with low molecular weight heparin (LMWH) and vitamin K antagonists (VKA). Literature evaluating NOAC use in the treatment of acute portal vein thrombosis is sparse. This review focuses on the safety and efficacy of the use of NOACs in the treatment of acute PVT in patients, with or without concomitant cirrhosis, based on the most recent data available in the current literature. METHODS A systematic review was conducted through a series of advanced searches in the following medical databases: PubMed, BioMed Central, Cochrane, and Google Scholar. Keywords utilized were as follows: NOAC, DOAC (direct oral anticoagulants), portal vein thrombosis, rivaroxaban, apixaban, dabigatran, and edoxaban. Articles related to newer anticoagulant use in patients with portal vein thrombosis were included. RESULTS The adverse events, including bleeding events (major and minor) and the failure of anticoagulation (propagation of thrombus or recurrence of PVT), are similar between the NOACs and traditional anticoagulants for the treatment of acute PVT, irrespective of the presence of cirrhosis. CONCLUSIONS Newer oral anticoagulants are safe and efficacious alternatives to traditional anticoagulation with low molecular weight heparin and vitamin K antagonists in the treatment of acute portal vein thrombosis with or without cirrhosis.
Collapse
|
24
|
Zimran E, Hoffman R, Kremyanskaya M. Current approaches to challenging scenarios in myeloproliferative neoplasms. Expert Rev Anticancer Ther 2018; 18:567-578. [PMID: 29575945 DOI: 10.1080/14737140.2018.1457441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs) including polycythemia vera, essential thrombocythemia and primary myelofibrosis are clonal hematological malignancies that originate at the level of the hematopoietic stem cell, and are characterized by excessive proliferation of cells belonging to one or more of the myeloid lineages. Central to the pathogenesis of the MPNs is constitutive activation of the JAK/STAT signaling pathway due to a family of driver mutations affecting JAK2, CALR or MPL. These disorders share common clinical and laboratory features, a significant burden of systemic symptoms, increased risk of developing arterial and venous thrombotic events, and the potential to progress to myelofibrosis and acute leukemia. Areas covered: We identified four clinical situations which represent challenging management dilemmas for patients with MPNs. Our conclusions and recommendations are based on a literature search using MEDLINE and recent meeting abstracts using the keywords, focusing on publications directly addressing these scenarios and on recent contributions to the field. Expert commentary: Multi-center efforts to study large cohorts of MPN patients have led to more uniform and evidence-based approaches to key aspects in MPN management. However, treatment strategies to deal with specific clinical scenarios are lacking.
Collapse
Affiliation(s)
- Eran Zimran
- a Icahn School of Medicine at Mount Sinai , Tisch Cancer Institute , New York , NY , USA
| | - Ronald Hoffman
- a Icahn School of Medicine at Mount Sinai , Tisch Cancer Institute , New York , NY , USA
| | - Marina Kremyanskaya
- a Icahn School of Medicine at Mount Sinai , Tisch Cancer Institute , New York , NY , USA
| |
Collapse
|
25
|
Janczak DT, Mimier MK, McBane RD, Kamath PS, Simmons BS, Bott-Kitslaar DM, Lenz CJ, Vargas ER, Hodge DO, Wysokinski WE. Rivaroxaban and Apixaban for Initial Treatment of Acute Venous Thromboembolism of Atypical Location. Mayo Clin Proc 2018; 93:40-47. [PMID: 29217335 DOI: 10.1016/j.mayocp.2017.10.007] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 09/19/2017] [Accepted: 10/10/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To assess the outcome of direct oral anticoagulants (DOACs), specifically Xa inhibitors: rivaroxaban and apixaban, for the treatment of venous thromboembolism (VTE) of atypical location (VTE-AL), portal, mesenteric, hepatic, splenic, gonadal, renal, and cerebral veins, prospectively collected data of Mayo Thrombophilia Clinic Registry were used. METHODS Patients with acute VTE-AL treated with DOACs, enrolled between March 1, 2013, and February 1, 2017, were compared with patients with VTE of typical location (VTE-TL: deep vein thrombosis of extremities and/or pulmonary embolism) receiving DOACs and with patients with VTE-AL treated with enoxaparin. RESULTS Out of 623 patients with acute VTE receiving the study drug within 14 days of diagnosis, there were 63 with VTE-AL: 36 on DOAC, 23 on enoxaparin, and 4 on warfarin; 352 received DOAC for VTE-TL. The VTE-AL treated with DOAC/enoxaparin included the following: splanchnic (26/22), ovarian (8/2), renal (3/5), and cerebral veins (1/1), respectively. Recurrence rate (per 100 person-years) for the VTE-AL group receiving DOAC was 7.3, which was not different when compared with those for VTE-TL (2.4; P=.13) and VTE-AL groups receiving enoxaparin (23.7; P=.37). Major bleeding rate in the VTE-AL group receiving DOAC was not different compared with those for VTE-TL (7.2 vs 3.0; P=.26) and VTE-AL groups on enoxaparin (22.4; P=.31). Mortality was higher in the VTE-AL group on DOAC compared with the VTE-TL group (21.45 [95% CI, 7.87-46.69] vs 8.26 [95% CI, 5.35, 12.20]; P=.03). All patients with VTE-AL with events had cancer. CONCLUSION The VTE recurrence and bleeding rates for rivaroxaban and apixaban used in VTE-AL are not different from those in patients with VTE-TL and similar to that for enoxaparin.
Collapse
Affiliation(s)
- Dawid T Janczak
- Faculty of Health Science, Division of Oncology and Palliative Care, Wroclaw Medical University, Poland
| | | | - Robert D McBane
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | | | - Charles J Lenz
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Emily R Vargas
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | | |
Collapse
|
26
|
Riva N, Ageno W. Approach to thrombosis at unusual sites: Splanchnic and cerebral vein thrombosis. Vasc Med 2017; 22:529-540. [PMID: 29202678 DOI: 10.1177/1358863x17734057] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Splanchnic vein thrombosis (SVT) and cerebral vein thrombosis (CVT) are two manifestations of unusual site venous thromboembolism (VTE). SVT includes thrombosis in the portal, mesenteric or splenic veins, and the Budd-Chiari syndrome. CVT encompasses thrombosis of the dural venous sinuses and thrombosis of the cerebral veins. Unusual site VTE often represents a diagnostic and therapeutic challenge because of the heterogeneity in clinical presentation, the limited evidence available in the literature on the acute and long-term prognosis of these diseases, and the lack of large randomized controlled trials evaluating different treatment options. This narrative review describes the approach to patients with SVT or CVT by examining the diagnostic process, the assessment of potential risk factors and the appropriate anticoagulant treatment.
Collapse
Affiliation(s)
- Nicoletta Riva
- 1 Department of Pathology, University of Malta, Msida, Malta
| | - Walter Ageno
- 2 Department of Medicine and Surgery, University of Insubria, Varese, Italy
| |
Collapse
|