Management of Portal Vein Thrombosis in Cirrhosis

Abstract

While portal vein thrombosis (PVT) is a frequently encountered complication in the cirrhosis population, its management can be challenging for even the most experienced clinicians. Multiple factors must be considered with regards to management, including the degree of underlying portal hypertension and liver dysfunction, risks of therapies including anticoagulation and transjugular intrahepatic portosystemic shunt placement, and extent of the thrombosis. Interpreting the available literature to determine the best treatment strategy for any individual patient can be especially challenging given the lack of prospective, randomized controlled trials and the heterogeneity of cohorts studied. This review will provide an overview of PVT in the cirrhosis population, including necessary steps in evaluation and the potential benefits and drawbacks of different treatment approaches.

Keywords

anticoagulation - TIPS - liver transplantation - mesenteric veins - portal hypertension

Publikationsverlauf

Artikel online veröffentlicht:
09. Februar 2021

• References

• 1 Nery F, Chevret S, Condat B. et al; Groupe d'Etude et de Traitement du Carcinome Hépatocellulaire. Causes and consequences of portal vein thrombosis in 1,243 patients with cirrhosis: results of a longitudinal study. Hepatology 2015; 61 (02) 660-667
• 2 Ma SD, Wang J, Bezinover D, Kadry Z, Northup PG, Stine JG. Inherited thrombophilia and portal vein thrombosis in cirrhosis: a systematic review and meta-analysis. Res Pract Thromb Haemost 2019; 3 (04) 658-667
• 3 Abdel-Razik A, Mousa N, Elhelaly R, Tawfik A. De-novo portal vein thrombosis in liver cirrhosis: risk factors and correlation with the Model for End-stage Liver Disease scoring system. Eur J Gastroenterol Hepatol 2015; 27 (05) 585-592
• 4 Stine JG, Wang J, Shah PM. et al. Decreased portal vein velocity is predictive of the development of portal vein thrombosis: a matched case-control study. Liver Int 2018; 38 (01) 94-101
• 5 Zocco MA, Di Stasio E, De Cristofaro R. et al. Thrombotic risk factors in patients with liver cirrhosis: correlation with MELD scoring system and portal vein thrombosis development. J Hepatol 2009; 51 (04) 682-689
• 6 Chen H, Turon F, Hernández-Gea V. et al. Nontumoral portal vein thrombosis in patients awaiting liver transplantation. Liver Transpl 2016; 22 (03) 352-365
• 7 Noronha Ferreira C, Marinho RT, Cortez-Pinto H. et al. Incidence, predictive factors and clinical significance of development of portal vein thrombosis in cirrhosis: a prospective study. Liver Int 2019; 39 (08) 1459-1467
• 8 Stine JG, Shah NL, Argo CK, Pelletier SJ, Caldwell SH, Northup PG. Increased risk of portal vein thrombosis in patients with cirrhosis due to nonalcoholic steatohepatitis. Liver Transpl 2015; 21 (08) 1016-1021
• 9 Berry K, Taylor J, Liou IW, Ioannou GN. Portal vein thrombosis is not associated with increased mortality among patients with cirrhosis. Clin Gastroenterol Hepatol 2015; 13 (03) 585-593
• 10 Qi X, De Stefano V, Su C, Bai M, Guo X, Fan D. Associations of antiphospholipid antibodies with splanchnic vein thrombosis: a systematic review with meta-analysis. Medicine (Baltimore) 2015; 94 (04) e496
• 11 Amitrano L, Ames PR, Guardascione MA. et al. Antiphospholipid antibodies and antiphospholipid syndrome: role in portal vein thrombosis in patients with and without liver cirrhosis. Clin Appl Thromb Hemost 2011; 17 (04) 367-370
• 12 Simonetto DA, Singal AK, Garcia-Tsao G, Caldwell SH, Ahn J, Kamath PS. ACG clinical guideline: disorders of the hepatic and mesenteric circulation. Am J Gastroenterol 2020; 115 (01) 18-40
• 13 Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the Study of Liver Diseases. Hepatology 2017; 65 (01) 310-335
• 14 Berzigotti A, García-Criado A, Darnell A, García-Pagán JC. Imaging in clinical decision-making for portal vein thrombosis. Nat Rev Gastroenterol Hepatol 2014; 11 (05) 308-316
• 15 Margini C, Berzigotti A. Portal vein thrombosis: the role of imaging in the clinical setting. Dig Liver Dis 2017; 49 (02) 113-120
• 16 Lai L, Brugge WR. Endoscopic ultrasound is a sensitive and specific test to diagnose portal venous system thrombosis (PVST). Am J Gastroenterol 2004; 99 (01) 40-44
• 17 Calvet X, Bruix J, Brú C. et al. Natural history of hepatocellular carcinoma in Spain. Five year's experience in 249 cases. J Hepatol 1990; 10 (03) 311-317
• 18 Stuart KE, Anand AJ, Jenkins RL. Hepatocellular carcinoma in the United States. Prognostic features, treatment outcome, and survival. Cancer 1996; 77 (11) 2217-2222
• 19 Tublin ME, Dodd III GD, Baron RL. Benign and malignant portal vein thrombosis: differentiation by CT characteristics. AJR Am J Roentgenol 1997; 168 (03) 719-723
• 20 Sandrasegaran K, Tahir B, Nutakki K. et al. Usefulness of conventional MRI sequences and diffusion-weighted imaging in differentiating malignant from benign portal vein thrombus in cirrhotic patients. AJR Am J Roentgenol 2013; 201 (06) 1211-1219
• 21 Hidaka H, Kokubu S, Sato T. et al; NPB-06 study group. Antithrombin III for portal vein thrombosis in patients with liver disease: a randomized, double-blind, controlled trial. Hepatol Res 2018; 48 (03) E107-E116
• 22 Luca A, Miraglia R, Caruso S. et al. Short- and long-term effects of the transjugular intrahepatic portosystemic shunt on portal vein thrombosis in patients with cirrhosis. Gut 2011; 60 (06) 846-852
• 23 Plessier A, Darwish-Murad S, Hernandez-Guerra M. et al; European Network for Vascular Disorders of the Liver (EN-Vie). Acute portal vein thrombosis unrelated to cirrhosis: a prospective multicenter follow-up study. Hepatology 2010; 51 (01) 210-218
• 24 De Gaetano AM, Lafortune M, Patriquin H, De Franco A, Aubin B, Paradis K. Cavernous transformation of the portal vein: patterns of intrahepatic and splanchnic collateral circulation detected with Doppler sonography. AJR Am J Roentgenol 1995; 165 (05) 1151-1155
• 25 Glatard AS, Hillaire S, d'Assignies G. et al. Obliterative portal venopathy: findings at CT imaging. Radiology 2012; 263 (03) 741-750
• 26 De Gottardi A, Rautou PE, Schouten J. et al; VALDIG group. Porto-sinusoidal vascular disease: proposal and description of a novel entity. Lancet Gastroenterol Hepatol 2019; 4 (05) 399-411
• 27 Dhiman RK, Behera A, Chawla YK, Dilawari JB, Suri S. Portal hypertensive biliopathy. Gut 2007; 56 (07) 1001-1008
• 28 Llop E, de Juan C, Seijo S. et al. Portal cholangiopathy: radiological classification and natural history. Gut 2011; 60 (06) 853-860
• 29 Qi X, Guo X, Yoshida EM. et al. Transient portal vein thrombosis in liver cirrhosis. BMC Med 2018; 16 (01) 83
• 30 Loffredo L, Pastori D, Farcomeni A, Violi F. Effects of anticoagulants in patients with cirrhosis and portal vein thrombosis: a systematic review and meta-analysis. Gastroenterology 2017; 153 (02) 480.e1-487.e1
• 31 La Mura V, Braham S, Tosetti G. et al. Harmful and beneficial effects of anticoagulants in patients with cirrhosis and portal vein thrombosis. Clin Gastroenterol Hepatol 2018; 16 (07) 1146.e4-1152.e4
• 32 Ageno W, Riva N, Schulman S. et al. Long-term clinical outcomes of splanchnic vein thrombosis: results of an international registry. JAMA Intern Med 2015; 175 (09) 1474-1480
• 33 Delgado MG, Seijo S, Yepes I. et al. Efficacy and safety of anticoagulation on patients with cirrhosis and portal vein thrombosis. Clin Gastroenterol Hepatol 2012; 10 (07) 776-783
• 34 Senzolo M, Sartori TM, Rossetto V. et al. Prospective evaluation of anticoagulation and transjugular intrahepatic portosystemic shunt for the management of portal vein thrombosis in cirrhosis. Liver Int 2012; 32 (06) 919-927
• 35 Rodriguez-Castro KI, Vitale A, Fadin M. et al. A prediction model for successful anticoagulation in cirrhotic portal vein thrombosis. Eur J Gastroenterol Hepatol 2019; 31 (01) 34-42
• 36 Francoz C, Belghiti J, Vilgrain V. et al. Splanchnic vein thrombosis in candidates for liver transplantation: usefulness of screening and anticoagulation. Gut 2005; 54 (05) 691-697
• 37 Chung JW, Kim GH, Lee JH. et al. Safety, efficacy, and response predictors of anticoagulation for the treatment of nonmalignant portal-vein thrombosis in patients with cirrhosis: a propensity score matching analysis. Clin Mol Hepatol 2014; 20 (04) 384-391
• 38 Kwon J, Koh Y, Yu SJ, Yoon JH. Low-molecular-weight heparin treatment for portal vein thrombosis in liver cirrhosis: efficacy and the risk of hemorrhagic complications. Thromb Res 2018; 163: 71-76
• 39 Chen H, Liu L, Qi X. et al. Efficacy and safety of anticoagulation in more advanced portal vein thrombosis in patients with liver cirrhosis. Eur J Gastroenterol Hepatol 2016; 28 (01) 82-89
• 40 Tripodi A, Primignani M, Braham S. et al. Coagulation parameters in patients with cirrhosis and portal vein thrombosis treated sequentially with low molecular weight heparin and vitamin K antagonists. Dig Liver Dis 2016; 48 (10) 1208-1213
• 41 Intagliata NM, Henry ZH, Maitland H. et al. Direct oral anticoagulants in cirrhosis patients pose similar risks of bleeding when compared to traditional anticoagulation. Dig Dis Sci 2016; 61 (06) 1721-1727
• 42 Bechmann LP, Sichau M, Wichert M, Gerken G, Kröger K, Hilgard P. Low-molecular-weight heparin in patients with advanced cirrhosis. Liver Int 2011; 31 (01) 75-82
• 43 Lisman T, Porte RJ. Towards a rational use of low-molecular-weight heparin in patients with cirrhosis. Liver Int 2011; 31 (07) 1063
• 44 Potze W, Adelmeijer J, Lisman T. Decreased in vitro anticoagulant potency of rivaroxaban and apixaban in plasma from patients with cirrhosis. Hepatology 2015; 61 (04) 1435-1436
• 45 Potze W, Arshad F, Adelmeijer J. et al. Differential in vitro inhibition of thrombin generation by anticoagulant drugs in plasma from patients with cirrhosis. PLoS One 2014; 9 (02) e88390
• 46 De Gottardi A, Trebicka J, Klinger C. et al; VALDIG Investigators. Antithrombotic treatment with direct-acting oral anticoagulants in patients with splanchnic vein thrombosis and cirrhosis. Liver Int 2017; 37 (05) 694-699
• 47 Hum J, Shatzel JJ, Jou JH, Deloughery TG. The efficacy and safety of direct oral anticoagulants vs traditional anticoagulants in cirrhosis. Eur J Haematol 2017; 98 (04) 393-397
• 48 Janczak DT, Mimier MK, McBane RD. et al. Rivaroxaban and apixaban for initial treatment of acute venous thromboembolism of atypical location. Mayo Clin Proc 2018; 93 (01) 40-47
• 49 Intagliata NM, Maitland H, Pellitier S, Caldwell SH. Reversal of direct oral anticoagulants for liver transplantation in cirrhosis: a step forward. Liver Transpl 2017; 23 (03) 396-397
• 50 Han G, Qi X, He C. et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosis. J Hepatol 2011; 54 (01) 78-88
• 51 Qi X, He C, Guo W. et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with variceal bleeding in liver cirrhosis: outcomes and predictors in a prospective cohort study. Liver Int 2016; 36 (05) 667-676
• 52 Thornburg B, Desai K, Hickey R. et al. Portal vein recanalization and transjugular intrahepatic portosystemic shunt creation for chronic portal vein thrombosis: technical considerations. Tech Vasc Interv Radiol 2016; 19 (01) 52-60
• 53 Thornburg B, Desai K, Hickey R. et al. Pretransplantation portal vein recanalization and transjugular intrahepatic portosystemic shunt creation for chronic portal vein thrombosis: final analysis of a 61-patient cohort. J Vasc Interv Radiol 2017; 28 (12) 1714-1721.e2
• 54 Intagliata NM, Argo CK, Stine JG, Lisman T, Caldwell SH, Violi F. faculty of the 7th International Coagulation in Liver Disease. Concepts and controversies in haemostasis and thrombosis associated with liver disease: Proceedings of the 7th International Coagulation in Liver Disease Conference. Thromb Haemost 2018; 118 (08) 1491-1506
• 55 Ghabril M, Agarwal S, Lacerda M, Chalasani N, Kwo P, Tector AJ. Portal vein thrombosis is a risk factor for poor early outcomes after liver transplantation: analysis of risk factors and outcomes for portal vein thrombosis in waitlisted patients. Transplantation 2016; 100 (01) 126-133
• 56 Englesbe MJ, Kubus J, Muhammad W. et al. Portal vein thrombosis and survival in patients with cirrhosis. Liver Transpl 2010; 16 (01) 83-90