Anticoagulant therapy in patients with liver cirrhosis and portal vein thrombosis: insights for the clinician

Portal vein thrombosis (PVT) is a frequent complication in the natural history of patients with liver cirrhosis (LC). The prevalence of PVT in LC is highly variable, ranging from 0.6% to 25% according to different reports. The impact of PVT on the natural history of LC is unclear, but it seems to negatively affect the prognosis of patients undergoing liver transplantation (LT) by increasing post-LT mortality and delaying waiting time. The antithrombotic treatment of PVT is still challenging as PVT may often remain asymptomatic and incidentally diagnosed, and a spontaneous partial/total regression of PVT is observed in an important proportion of patients, even in the absence of anticoagulation. Recent evidence suggested that the anticoagulant treatment for PVT may favorably affect both ischemic and bleeding outcomes in LC patients. Anticoagulant therapies so far available include unfractioned heparin, low molecular weight heparins (LMWHs) and fondaparinux for acute treatment, and LMWHs and vitamin K antagonists (VKAs) for long-term treatment. No robust data currently support the use of direct oral anticoagulants (DOACs) in patients with LC and PVT, as the safety and efficacy of DOACs in this setting is still unclear. This review summarizes current evidence for the evaluation and management of patients with LC and PVT.

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S2300 Duodenal Variceal Bleed Due to Iliocolic Arteriovenous Fistula and Portal Vein Thrombosis in a Patient Without a History of Liver Cirrhosis

The American Journal of Gastroenterology ◽

10.14309/01.ajg.0000782732.08236.c0 ◽

2021 ◽

Vol 116 (1) ◽

pp. S980-S980

Author(s):

Dominic Amakye ◽

Prakash Adhikari ◽

Susan Waitimu ◽

Michael West

Keyword(s):

Liver Cirrhosis ◽

Portal Vein ◽

Arteriovenous Fistula ◽

Portal Vein Thrombosis ◽

Vein Thrombosis ◽

Variceal Bleed ◽

History Of

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Anticoagulation Increases Bleeding Rates in Portal Vein Thrombosis: A National Database Study

Blood ◽

10.1182/blood-2019-131226 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 5860-5860

Author(s):

Omar Ali Alaber ◽

Apoorva Krishna Chandar ◽

Basma Ali Dahash ◽

Sohi N Mistry ◽

Stanley Martin Cohen ◽

...

Keyword(s):

Liver Cirrhosis ◽

Portal Vein ◽

Portal Vein Thrombosis ◽

Current Evidence ◽

National Database ◽

Insurance Status ◽

Vein Thrombosis ◽

Cirrhotic Patients ◽

Newer Anticoagulants ◽

First Time

Introduction: Liver cirrhosis is being increasingly recognized as a hypercoagulable state, mainly due to disproportionate reduction in antithrombotic factors (protein C, S and anti-thrombin III). Portal vein thrombosis (PVT) is a frequent sequala of liver cirrhosis that can lead to numerous complications and potential exclusion from transplant lists, at least until the resolution of the thrombus. The current evidence for anticoagulation (AC) for PVT in liver cirrhosis is limited to small retrospective studies. Major liver societies recommend limited anticoagulation with enoxaparin based on expert opinion (Category C). We sought to examine the incidence of bleeding after AC in cirrhotic patients with PVT. Methods: Data were obtained from a commercial de-identified database (Explorys, IBM, Inc.) that integrates electronic health records from 27 major integrated U.S. healthcare systems from 1999 to July 2019. Cases were defined as adult patients aged >=18 years having a new Systematized Nomenclature of Medicine Clinical Terms (SNOMED) diagnosis of PVT, had been anticoagulated for the first time following PVT and had experienced bleeding for the first time following AC. Controls were adults who had a diagnosis of PVT and did not get AC. We included older anticoagulants (warfarin and enoxaparin) as well as newer anticoagulants (apixaban, fondaparinux and rivaroxaban). We compared the incidence of bleeding (defined as bleeding from any site) in those with PVT who received AC to those with PVT who did not receive AC. In addition, we also compared the incidence of bleeding between older and newer anticoagulants, and also examined whether there were differences in gender, race, and insurance status for those who bled while on AC. Analysis comprised of calculating odds ratios (OR) and confidence intervals (CI) for the OR. Results: A total of 213,810 patients had liver cirrhosis and out of those, 7,570 (3.5%) patients had PVT. Four hundred and ten cases out of 1,430 patients who received AC bled for the first time whereas 980 cases out of 3,880 patients who did not receive AC bled for the first time. Cases on AC had 1.18 times higher odds of bleeding when compared to controls who did not receive AC (CI = 1.04 - 1.36). Newer AC were less likely to increase bleeding when compared to older AC (OR = 0.6, CI = 0.4 - 0.9). Females were significantly more likely to be first time bleeders on AC when compared to male first-time bleeders on AC (Table 1). However, race and insurance status did not seem to affect bleeding rates (Table 1). Conclusion: Anticoagulation for PVT in liver cirrhosis increases bleeding events. Newer AC were significantly less likely to increase bleeding when compared to older AC. Females were more likely to bleed on newer AC than males, but race and insurance status did not affect bleeding rates. Limitations of the study include the retrospective nature of the analysis that relied on diagnosis coding, and smaller numbers in our subgroup analyses which limits generalizability. Clinicians should be aware of the significant risk of bleeding when prescribing AC, particularly older AC to cirrhotic patients with PVT. Disclosures No relevant conflicts of interest to declare.

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Non tumoral portal vein thrombosis during cirrhosis: Should anticoagulation be proposed?

10.32512/jmr.1.2.2018/4.11. ◽

2018 ◽

Keyword(s):

Portal Vein ◽

Portal Vein Thrombosis ◽

Anticoagulant Therapy ◽

Control Group ◽

Case Group ◽

Early Introduction ◽

Vein Thrombosis ◽

History Of ◽

One Year ◽

The Impact

Background: Portal vein thrombosis (PVT) is considered as infrequent and pejorative event in cirrhosis. Up to date, many questions remain about therapeutic management. Aim: The objectives of this study were to assess the impact of the PVT on the progression of liver disease, to review the indications for anticoagulation and its repercussions. Materials and methods: A case-control study was conducted over a period of 12 years (2002-2013). It included 484 cases of cirrhosis. Among these patients, 41 had non tumoral portal vein thrombosis (case group). The control group included the remaining 443 patients. Results: In our study, there was no impact of PVT on the natural history of cirrhosis both in terms of complications or survival. Only the early introduction of anticoagulant therapy was associated with a re-permeabilization of portal vein at one year (OR1.6; 95% CI [1.10-2.01]). Prolonged anticoagulation was inversely correlated with recurrent PVT after treatment. However, obtaining a portal vein re-permeabilization was not correlated to a significant gain in terms of prevention of complication related to cirrhosis and survival. Conclusions: results suggest that portal vein thrombosis in patients with cirrhosis is not a formal indication for anticoagulant therapy. It should be reserved for candidates of liver transplantation, those with an extension of the PVT to mesenteric vessels or with severe prothrombotic status. Key words: portal vein thrombosis, cirrhosis, anticoagulation.

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New Insights into the Pathogenesis, Risk Factors, and Treatment of Portal Vein Thrombosis in Patients with Cirrhosis

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0040-1715473 ◽

2020 ◽

Vol 46 (06) ◽

pp. 673-681 ◽

Cited By ~ 1

Author(s):

Oana Nicoară-Farcău ◽

Guillem Soy ◽

Marta Magaz ◽

Anna Baiges ◽

Fanny Turon ◽

...

Keyword(s):

Risk Factors ◽

Portal Vein ◽

Portal Vein Thrombosis ◽

Current Knowledge ◽

Current Evidence ◽

Special Focus ◽

Vein Thrombosis ◽

Frequent Event ◽

Intrahepatic Portosystemic Shunt ◽

History Of

AbstractPortal vein thrombosis (PVT) is a frequent event in patients with cirrhosis regardless of etiology. Notwithstanding the commonality of the problem, the pathophysiology and risk factors for PVT in cirrhosis are largely unknown. The clinical impact of PVT in the natural history of cirrhosis is unclear, indications for PVT treatment are not well defined, and treatment recommendations are based on experts' opinion and consensus only. Therefore, this review aims to summarize current knowledge of mechanisms and risk factors for PVT development and assess the current evidence of PVT management, with a special focus on strategies of anticoagulation and transjugular intrahepatic portosystemic shunt placement.

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Giant Splenorenal Shunt in a Young Patient with Autoimmune Hepatitis/Primary Biliary Cholangitis Overlap Syndrome and Portal Vein Thrombosis

Case Reports in Radiology ◽

10.1155/2017/2167364 ◽

2017 ◽

Vol 2017 ◽

pp. 1-5

Author(s):

F. Chegai ◽

A. U. Cavallo ◽

M. Forcina ◽

V. Giuricin ◽

F. Castellani ◽

...

Keyword(s):

Portal Vein ◽

Autoimmune Hepatitis ◽

Portal Vein Thrombosis ◽

Overlap Syndrome ◽

Splenorenal Shunt ◽

Maximum Diameter ◽

Primary Biliary Cholangitis ◽

Vein Thrombosis ◽

History Of ◽

The Impact

We present a case of giant Splenorenal Shunt (SRS) associated with portal vein thrombosis in a 37-year-old woman with a twelve-year history of autoimmune hepatitis/primary biliary cholangitis overlap syndrome. At the moment of the CT examination laboratory tests showed creatinine 1.5 mg/dl, bilirubin 1.5 mg/dl, INR 3, and Na 145 mmol/l and the Model End-Stage Liver Disease score was 24. Extensive calcified thrombosis causing complete occlusion of the portal vein lumen and partially occluding the origin of the superior mesenteric vein was present and a small calcified thrombus in the Splenic Vein lumen was also evident. SRS was located among the spleen hilum and the left kidney with a maximum diameter of 3.25 cm and was associated with dilatation of left renal vein and inferior vena cava. After a multidisciplinary evaluation the patient was put on the Regional Liver Transplant waiting list and liver transplantation was performed successfully. Although portal vein thrombosis and SRS are common occurrences in cirrhotic patients, the impact in the natural history of the disease is still unclear. Careful management and accurate imaging protocols are essential in the evaluation of those patients.

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Clinical features and natural history of portal vein thrombosis after radiofrequency ablation for hepatocellular carcinoma in Japan

Hepatology International ◽

10.1007/s12072-013-9470-z ◽

2013 ◽

Vol 7 (4) ◽

pp. 1030-1039 ◽

Cited By ~ 3

Author(s):

Taro Shimada ◽

Hitoshi Maruyama ◽

Takayuki Kondo ◽

Tadashi Sekimoto ◽

Masanori Takahashi ◽

...

Keyword(s):

Hepatocellular Carcinoma ◽

Radiofrequency Ablation ◽

Natural History ◽

Portal Vein ◽

Portal Vein Thrombosis ◽

Clinical Features ◽

Vein Thrombosis ◽

History Of

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Impact of Portal Vein Thrombosis on Endoscopic Variceal Band Ligation in Liver Cirrhosis

Journal of Healthcare Engineering ◽

10.1155/2021/9929333 ◽

2021 ◽

Vol 2021 ◽

pp. 1-6

Author(s):

Yue Huang

Keyword(s):

Liver Cirrhosis ◽

Gastrointestinal Bleeding ◽

Portal Vein ◽

Portal Vein Thrombosis ◽

Variceal Bleeding ◽

Band Ligation ◽

Vein Thrombosis ◽

End Point ◽

Retrosternal Pain ◽

The Impact

Background. Portal vein (PV) thrombosis (PVT) is a common complication of liver cirrhosis and can refer to thrombosis within the PV that can extend to its left or right branches and in some cases to the superior mesenteric vein or the splenic vein (Chawla and Bodh, 2015). For severe PVT patients, there are possibilities of increasing PV resistance and reduction of the blood flow though PV towards liver, which exacerbate liver function damage meanwhile elevating the gastrointestinal variceal bleeding risk. Endoscopic Variceal band ligation (EVL) is often used to prevent esophageal variceal bleeding; postoperative complications such as severe gastrointestinal bleeding and bleeding-related death, fever, retrosternal pain, and esophageal stenosis may appear. There was absence of the research which evaluated the impact of PVT in liver cirrhosis on the complication of endoscopic Variceal band ligation for now. We herein aimed to compare cirrhosis patients with and without PVT of recent complications after EVL. Method. We established the retrospective investigation on 144 consecutive cirrhosis patients (excluding patients with hepatocellular carcinoma and who received portal vein-systemic circulation devascularization or shunt surgery, splenectomy, hepatectomy, liver transplantation, transjugular intrahepatic portal vein stent shunt (TIPS), endoscopic varices Variceal ligation, or sclerotherapy before) who have received first endoscopic esophageal varices band ligation in Gastrointestinal Endoscopy Center of the First Affiliated Hospital, College of Medicine, ZheJiang University, between January 2014 and December 2017. Portal vein Doppler ultrasonography, liver computerized tomography (CT), and angiography or liver-enhanced magnetic resonance imaging (MRI) were applied to evaluate the portal vein thrombosis of each patient before EVL. There were 18 patients confirmed with portal vein thrombosis while the other 126 patients without PVT. The primary end point for this research is the upper gastrointestinal hemorrhage and related death occurred from the date of ligation until leaving hospital, and the secondary end point is the appearance of postoperative fever and retrosternal pain. Results. There are no significant differences of gastrointestinal bleeding, bleeding-related death, fever, or retrosternal pain after EVL and the length of hospital stays between cirrhotic patients with or without PVT ( P = 0.34 , 0.51 , 0.58 , 0.61 , 0.88 ). Conclusion. Liver cirrhosis with portal vein thrombosis did not increase incidence of recent complications of the endoscopic Variceal band ligation.

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