Portal Hypertension–Related Complications After Acute Portal Vein Thrombosis: Impact of Early Anticoagulation

doi:10.1016/j.cgh.2008.07.031

Clinical Gastroenterology and Hepatology

Volume 6, Issue 12, December 2008, Pages 1412-1417

https://doi.org/10.1016/j.cgh.2008.07.031 Get rights and content

Background & Aims

Acute portal vein thrombosis (APVT) is a rare disorder that causes chronic portal hypertension if recanalization is not obtained. However, response to anticoagulation and long-term prognosis of APVT are not well-defined.

Methods

Thirty-eight patients diagnosed with APVT between 1995 and 2003 from 5 Spanish referral hospitals, in whom cirrhosis and malignancy were specifically excluded, were included in this retrospective study. The response to anticoagulation therapy and development of portal hypertension–related complications during follow-up were evaluated.

Results

Mean follow-up was 43 months (range, 6–112 months). Recanalization occurred in 12 of 27 patients receiving anticoagulation versus 0 of 11 patients who did not receive anticoagulation (P = .008). Rates of recanalization were influenced by the precocity of heparin administration and the number of underlying prothrombotic conditions. Follow-up upper endoscopy performed in 29 patients disclosed gastroesophageal varices in 16 (55%). Varices appeared as early as 1 month after APVT. However, in most patients varices were detected in successive endoscopies, mainly during the first year. Two-year actuarial probability of variceal bleeding was 12% and for ascites 16%. Five-year survival was 87%. Mortality was related to the APVT episode in 2 cases and to an underlying hematologic disorder in one.

Conclusions

Anticoagulation achieved recanalization in about 40% of patients. Most patients not achieving recanalization will develop gastroesophageal varices during follow-up. However, development of variceal bleeding and ascites is infrequent, and survival is satisfactory.

Section snippets

Study Cohort

This retrospective study included all patients who had been diagnosed with AVPT in the gastroenterology or surgical units of 5 reference hospitals in Spain between January 1995 and September 2003. The diagnosis of APVT was made on the basis of recent abdominal pain and without signs of chronic portal hypertension. The exclusion critieria included those patients with portal cavernoma or the presence of collateral portosystemic circulation by using Doppler ultrasound, computed tomography (CT)

Results

Thirty-eight patients were included in the study (Table 1). Mean age at diagnosis was 49 years (range, 17–74 years). Mean follow-up in 36 patients surviving the acute episode was 43 months (range, 6–112 months). Diagnosis of thrombosis of portal, mesenteric, or splenic veins was based on data obtained from Doppler ultrasound in 31 subjects (81.6%), CT scan in 32 subjects (84.2%), magnetic resonance angiography in 9 subjects (23.7%), and angiography in 7 subjects (18.4%). Two or more imaging

Discussion

During the past 2 decades, several studies have focused on the etiology, clinical manifestations, and management of complications related to portal hypertension–related complications in patients with portal vein cavernoma.13, 14, 15, 16, 17, 18, 19 However, the natural history of patients with symptomatic APVT and the impact of early anticoagulation on outcome have hardly been studied. Up until now there has only been one small study assessing the etiology and response to anticoagulant therapy

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The knowledge of natural history and prognostic factors of portal vein thrombosis (PVT) is still based on a limited number of studies.
To describe our single-center experience with 79 consecutive non-neoplastic non-cirrhotic patients with PVT (15 recent/64 chronic PVT).
Among patients with recent PVT, 7 received anticoagulation alone, 4 systemic thrombolysis, 3 direct thrombolysis through a TIPS and 1 TIPS alone. Portal recanalization was achieved in 11 patients. In patients with chronic PVT, the rate of variceal progression was high (20% at one year and 50% at two years). The thrombotic involvement of splenic and superior mesenteric veins was the only risk factor for variceal enlargement. The cumulative bleeding rates were 10% at one year and 20% at two years. A multisegmental thrombosis and large varices at entry and a previous variceal bleeding were the independent predictors for variceal bleeding. The cumulative rate of new thrombotic events was 14% at one year and 18% at two years. Eight patients died, 2 because of thrombotic events. There were no bleeding-related deaths. Two-year cumulative survival rate was 90%.
Our study supports the importance of anticoagulation especially when a more extended thrombosis is present. Moreover, in patients with chronic PVT, the timing of follow-up endoscopy should be based on the extension of thrombosis and not, as in cirrhosis, on the size of varices at first endoscopy.
Transjugular Intrahepatic Portosystemic Shunt and Thrombectomy (TIPS-Thrombectomy) for Symptomatic Acute Noncirrhotic Portal Vein Thrombosis
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To report the safety and effectiveness of transjugular intrahepatic portosystemic shunt and mechanical thrombectomy (TIPS-thrombectomy) for symptomatic acute noncirrhotic portal vein thrombosis (NC-PVT).
Patients with acute NC-PVT who underwent TIPS-thrombectomy between 2014 and 2021 at a single academic medical center were retrospectively reviewed. Thirty-two patients were included (men, 56%; median age, 51 years [range, 39–62 years]). The causes for PVT included idiopathic (n = 12), prothrombotic disorders (n = 11), postsurgical sequelae (n = 6), pancreatitis (n = 2), and Budd-Chiari syndrome (n = 1). The indications for TIPS-thrombectomy included refractory abdominal pain (n = 14), intestinal venous ischemia (n = 9), ascites (n = 4), high-risk varices (n = 3), and variceal bleeding (n = 2). Variables studied included patient, disease, and procedure characteristics. Patients were monitored over the course of 1-year follow-up.
Successful recanalization of occluded portal venous vessels occurred in all 32 patients (100%). Compared with pretreatment patency, recanalization with TIPS-thrombectomy resulted in an increase in patent veins (main portal vein [28% vs 97%, P < .001], superior mesenteric vein [13% vs 94%, P < .001], and splenic vein [66% vs 91%, P < .001]). Three procedure-related adverse events occurred (Society of Interventional Radiology grade 2 moderate). Hepatic encephalopathy developed in 1 (3%) of 32 patients after TIPS placement. At 1-year follow-up, return of symptoms occurred in 3 (9%) of 32 patients: (a) ascites (n = 1), (b) variceal bleeding (n = 1), and (c) intestinal venous ischemia (n = 1). The intention-to-treat 1-year portal vein and TIPS primary and secondary patency rates were 78% (25/32) and 100% (32/32), respectively. Seven patients required additional procedures, and the 1-year mortality rate was 3% (1/32).
TIPS-thrombectomy is a safe and effective method for treating patients with symptomatic acute NC-PVT.
Management of splanchnic vein thrombosis
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The expression splanchnic vein thrombosis encompasses Budd-Chiari syndrome and portal vein thrombosis. These disorders have common characteristics: they are both rare diseases which can cause portal hypertension and its complications. Budd-Chiari syndrome and portal vein thrombosis in the absence of underlying liver disease share many risk factors, among which myeloproliferative neoplasms represent the most common; a rapid comprehensive work-up for risk factors of thrombosis is needed in these patients. Long-term anticoagulation is indicated in most patients. Portal vein thrombosis can also develop in patients with cirrhosis and in those with porto-sinusoidal vascular liver disease. The presence and nature of underlying liver disease impacts the management of portal vein thrombosis. Indications for anticoagulation in patients with cirrhosis are growing, while transjugular intrahepatic portosystemic shunt is now a second-line option. Due to the rarity of these diseases, studies yielding high-grade evidence are scarce. However, collaborative studies have provided new insight into the management of these patients. This article focuses on the causes, diagnosis, and management of patients with Budd-Chiari syndrome, portal vein thrombosis without underlying liver disease, or cirrhosis with non-malignant portal vein thrombosis.
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To assess technical feasibility and safety of portal vein thrombectomy with suction thrombectomy using a large-bore thrombectomy device for portomesenteric venous thrombosis (PMVT).
After receiving approval from institutional review board, patients undergoing PMVT treatment using a large-bore aspiration thrombectomy device (Inari FlowTriever or ClotTriever) between July 2019 and June 2021 were identified at 2 medical centers. Charts were reviewed for demographic information, imaging findings, and procedural details. PMVT was categorized using the Yerdel grading system. The thrombectomy procedure was performed via transjugular access through the existing or a new transjugular intrahepatic portosystemic shunt (TIPS) or transsplenic or transhepatic approach. Technical success was defined as successful clot reduction and restoration of portal venous flow at the conclusion of the procedure. Patient outcomes based on clinical presentation, adverse events, and thrombectomy-associated adverse events were recorded.
Twenty patients, with a median age of 58 years (range, 23–72 years), underwent large-bore aspiration thrombectomy, which was technically successful in 19 of 20 (95%) patients. In 9 of 20 (45%) patients, 9 of 20 (45%) patients, and 2 of 20 (10%) patients, the 20-F, 16-F, and 24-F devices were used, respectively. Fourteen patients had a pre-existing TIPS, and 6 patients had a TIPS created. In 5 of 20 (25%) patients, overnight lysis was performed in conjunction with Inari thrombectomy. Thrombus resolution with restoration of flow was achieved in 19 of 20 (95%) cases. There were no thrombectomy-associated adverse events. The mean follow-up time was 70 days (±113) at which time primary patency of the portal venous system was present in 16 of 20 (80%) patients.
Large-bore aspiration portal vein thrombectomy is feasible for PMVT.
Splenomegaly in patients with primary or secondary myelofibrosis who are candidates for allogeneic hematopoietic cell transplantation: a Position Paper on behalf of the Chronic Malignancies Working Party of the EBMT
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Splenomegaly is a hallmark of myelofibrosis, a debilitating haematological malignancy for which the only curative option is allogeneic haematopoietic cell transplantation (HCT). Considerable splenic enlargement might be associated with a higher risk of delayed engraftment and graft failure, increased non-relapse mortality, and worse overall survival after HCT as compared with patients without significantly enlarged splenomegaly. Currently, there are no standardised guidelines to assist transplantation physicians in deciding optimal management of splenomegaly before HCT. Therefore, the aim of this Position Paper is to offer a shared position statement on this issue. An international group of haematologists, transplantation physicians, gastroenterologists, surgeons, radiotherapists, and radiologists with experience in the treatment of myelofibrosis contributed to this Position Paper. The key issues addressed by this group included the assessment, prevalence, and clinical significance of splenomegaly, and the need for a therapeutic intervention before HCT for the control of splenomegaly. Specific scenarios, including splanchnic vein thrombosis and COVID-19, are also discussed. All patients with myelofibrosis must have their spleen size assessed before allogeneic HCT. Myelofibrosis patients with splenomegaly measuring 5 cm and larger, particularly when exceeding 15 cm below the left costal margin, or with splenomegaly-related symptoms, could benefit from treatment with the aim of reducing the spleen size before HCT. In the absence of, or loss of, response, patients with increasing spleen size should be evaluated for second-line options, depending on availability, patient fitness, and centre experience. Splanchnic vein thrombosis is not an absolute contraindication for HCT, but a multidisciplinary approach is warranted. Finally, prevention and treatment of COVID-19 should adhere to standard recommendations for immunocompromised patients.
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Citation Excerpt :
AC therapy prevents clot extension, promotes recanalization of occluded vessels, reduces the likelihood of future PH (if it is not present at the time of diagnosis), and prevents recurrent thrombosis [53]. Some retrospective data suggest that earlier initiation of AC therapy may be associated with a higher probability of vessel recanalization and a lower risk of development of PH [54]. However, it is important to highlight that patients with MPN-SVT have a lower recanalization rate as compared to SVT from other etiologies.
Splanchnic vein thrombosis (SVT) in the setting of myeloproliferative neoplasm (MPN) is a unique clinical entity that requires close interdisciplinary coordination for proper diagnosis and management. The pathobiology of MPN-SVT is not fully understood, but recent developments have revealed the central role of endothelial cells. In this multidisciplinary review, we summarize the epidemiology of MPN-SVT and then critically evaluate the pathogenic features of this complication, with a focus on endothelial cell biology. We then discuss diagnostic considerations, including imaging modalities and MPN-specific investigations. Finally, we critically review the evidence supporting clinical management of MPN-SVT, including anticoagulation, interventional radiology procedures, MPN-related therapies, and liver transplantation. We conclude that further studies are needed to improve our understanding of MPN-SVT and the outcomes of patients with this debilitating complication.

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The authors disclose the following:

The authors are indebted to Ms M. A. Baringo, L. Rocabert, and R. Saez for their expert technical assistance. The authors also express their gratitude to Ms Clara Esteva for her secretarial support.

: Supported in part by grants from Ministerio de Educación y Ciencia (SAF-07/61298, BFU2006-092890/BFI), from Instituto de Salud Carlos III (FIS 06/0623), and from Fundación Española para el Estudio de las Enfermedades Hepáticas. Ciberehd is funded by Instituto de Salud Carlos III.

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Original article—liver, pancreas, and biliary tractPortal Hypertension–Related Complications After Acute Portal Vein Thrombosis: Impact of Early Anticoagulation

Background & Aims

Methods

Results

Conclusions

Section snippets

Study Cohort

Results

Discussion

Hepatology

J Hepatol

J Hepatol

J Hepatol

Am J Surg

Blood

Gastroenterology

Hepatology

Hepatology

Lancet

Extrahepatic portal vein obstruction

Semin Liver Dis

Original article—liver, pancreas, and biliary tract
Portal Hypertension–Related Complications After Acute Portal Vein Thrombosis: Impact of Early Anticoagulation