Editorial
Copyright ©The Author(s) 2015.
World J Gastroenterol. Jun 14, 2015; 21(22): 6769-6784
Published online Jun 14, 2015. doi: 10.3748/wjg.v21.i22.6769
Table 1 Key studies of portal vein thrombosis and liver transplantation
Number of patientsPrevalence PVT, n (%)PVT characteristicsOutcomes
Englesbe et al[65]22291 (2001-2007)897 (4.02)Not describedPVT was not predictive of waiting list mortality (HR = 0.90, P = 0.23)
PVT was predictive of post-transplant mortality (HR = 1.32, P = 0.02)
Sringeri et al[61]1491 (2000-Aug 2012)119 (8.0)Not describedProlonged theatre timea, increased blood transfusion rates1. No difference mortality up-to 140 mo
Ravaioli et al[13]889 (1998-2008)91 (10.2)Partial 51 (56%)No difference 1 yr (85% vs 86%) and 5 yr (68% vs 73%) survival between PVT and non-PVT subjects
Complete 40 (44%)Survival improved significantly for patients with complete PVT in the second era (2003-2008) (57% vs 89% at 1 yr1)
Yerdel et al[15]779 (1987-1996)63 (8.1)Grade 1: 24,Reduced 5 yr survival between PVT and non-PVT subjects (65.3% vs 76.3%1)
Grade 2: 23,
Grade 3: 6,But improved 5 yr survival from 1st to 2nd era in all patients (from 72% to 83%1)
Grade 4: 10
Table 2 Summary of studies reporting the use of anticoagulation for portal vein thrombosis in cirrhosis
Study typen (controls)Baseline severity liver diseaseDuration and type of anticoagulationPVT characteristics(none/partial/complete occlusion)RecanalisationPartial recanalisation/ stabilisationProgressionBleeding complicaitons
Francoz et al[7]Prospective case control19 (10)mean MELD 12.8Warfarin (INR 2-3)0/18/18/19 (42%) vs 0/10 non-anti-coagulated (P = 0.002)011 bleeding episode following endoscopic variceal band ligation
Mean 8.1 mo
Amitrano et al[83]Prospective28?Enoxaparin 200 IU/kg per day: 6 mo for responders and non-responders. Partial responders continue until end of follow up.0/23/521 (75%) at median 11 mo5 (17.9%)2Mild anaemia in patient with portal hypertensive gastropathy
Delgado et al[84]Retrospective55mean MELD 12.8 +/- 3.8Warfarin (INR 2-3) or enoxaparin mean 6.8 mo0/41/1425 (45.5%)30 (54.5%)06 variceal bleeds, 1 lower GI bleed, 1 obscure GI bleed, 1 oral bleed post-dental extraction, 1 severe vaginal bleed
Senzolo et al[85]Prospective case control33 (21)MELD 12.6 (controls MELD 13.7)Nadraparin low molecular weight heparin until end of follow up, or until 6 mo following complete recanalisation.0/24/1112/33 (36%) active arm vs 1/21 (5%) controlsPartial: 9/33 active arm. Stabilisation: 7/33 active arm. Partial recanalisation or stabilisation in 5/21 controls.5/33 (14.3%) active arm vs 15/21 (71.4%) control arm (P < 0.001)Active arm: 1 cerebral haemorrhage, 1 epistaxis, 1 haematuria, 1 variceal bleed
Control arm: 5 variceal bleeds
Werner et al[86]Retrospective28MELD 7-29Warfarinnot described11 (39.3%)17 (60.7%)01 significant vaginal bleed
Mean 302 d
Villa et al[55]Prospective randomised controlled trial34 (36)Child’s 7-10Enoxaparin 4000 IU/dPrimary prevention study: No PVTs at baselineN/AN/ATreatment arm: No PVT at 2 yr. Control arm: PVT in 10/36 (27.8%) at 2 yr (P = 0.001)Active arm: 2 variceal bleeds, 2 epistaxis
48 wk treatment. Follow up to 2 yrControl arm: 1 variceal bleed, 1 epistaxis
Table 3 Summary of new oral anti-coagulants
NameDabigatranApixabanEdoxabanRivaroxaban
ActionDirect thrombin inhibitorActivated factor Xa inhibitorActivated factor Xa inhibitorActivated factor Xa inhibitor
Clearance80% renal clearance73% hepatic50% hepatic65% hepatic
27% renal clearance50% renal clearance35% renal clearance
CYP3A4 interaction?NoYes (minor)MinimalYes
Absorption with food?No effectNo effectUp to 20% more40% more therefore intake with food
Elimination half life12-17 h12 h9-11 h8-9 h young
11-13 h elderly
Table 4 Summary of retrospective case series reporting the use of transjugular intrahepatic portosystemic stent-shunt for portal vein thrombosis in cirrhosis
Study type and stent characteristicsnBaseline severity liver disease: Child’s A/B/C (%)TIPSS indication (%)PVT characteristics: Complete/ partial/ cavernoma (%)Successful cannulation (%)OutcomeSignificant complications/ notes
Luca et al[102]Series 2003-201070A: 17 (24)Bleeding: 48Complete: 2470/70 (100) cannulation.Complete recanalisation in 40 (57%): 38 maintained patency at mean follow up 20.7 mo.
13 bare Wallstent, 57 covered Viatorr ePTFE covered (WL Gore and Associates)B: 42 (60)Ascites/ hydrothorax: 18Cavernoma: 2Complete recanalisation or significant reduction in thrombosis: 61 (87)
C: 11 (16)Specific treatment of PVT: 4
Perarnau et al[100]Series 1990-200434A: 3 (14)Bleeding: 27 (79)Complete acute: 15No cavernoma: 15/15 (100)Mean F/U 30 mo.Failed cannulation in presence of thrombosed intrahepatic PV branches or peri-hilar cavernoma
Palmaz (Cordis) or Wallstent (Boston Scientific) bare stentsB: 11 (52)Ascites: 5 (15)Complete + cavernoma: 19Cavernoma: 12/19 (63)26/34 (72%) long-term patency
C: 7 (33)Other: 2
(incomplete details)
Senzolo et al[104]Series 1994-200528 (15 non-cirrhotic)Not statedBleeding: 15Complete: 8 (3 with, 5 without cavernoma)19/28 (73%)Primary patency mean 18 mo in 14/19.
26 Memotherms (Angiomed) bare stents, 3 Viatorr covered stentsAscites: 5Partial: 5Stent thrombosis in 2 non-cirrhotic subjects (Budd-Chiari syndrome)
Portal biliopathy: 3
Specific treatment PVT: 1
Han et al[99]Series 2001-200857A: 25 (44)Bleeding: 56Complete: 14Overall: 43/57 (75)Primary patency maintained in 26/43 (17 required shunt revisions to maintain patency)Failure related to presence of cavernoma.
Uncovered stents in all patientsB: 26 (46)Ascites: 1Cavernoma: 30Complete PVT: 8/14 (57)1 case of delayed severe intra-abdominal haemorrhage following percutaneous trans-hepatic approach.
C: 6 (30)Partial: 35Partial PVT: 35/35 (100)
Cavernoma: 16/30 (53%)
Van Ha et al[106]Series 1995-200315B: 11 (73)Bleeding: 10Complete: 4/partial: 7/complete with cavernoma: 4Overall: 13/15 (87)Mean F/U 17 mo.
12 bare Wallstent (Boston Scientific), 1 bare Zilver stent (Cook)C: 4 (27)Ascites: 5Cavernoma: 3/41 stent occlusion
No cavernoma: 10/11 (91)
D’Avola et al[101]Series 1995-200915 (+ 8 controls with PVT)Mean Child’s 8Prevention of complete PVT pre-liver transplant: 8All partial PVTSeries describes only patients who successfully underwent TIPSS3/15 TIPSS thrombosis: all successfully treated.
Bare and covered stentsBleeding: 6Median time TIPSS to transplant: 185 d.
Ascites: 1100% portal vein patency at time of transplant vs 50% patency at transplant in controls (P = 0.008)
Bauer et al[103]Series 1999-20059Cirrhosis: disease severity not statedPrimary indication: maintain PV patency for future liver transplantationComplete: 7Series describing only patients who successfully underwent TIPSS1/9 re-thrombosed.
3 covered stents: others bare stentPartial: 22 patients transplanted with no PVT present
Cavernoma: 4
Blum et al[114]Case series7Cirrhosis: disease severity not statedBleeding: 7PVT severity not stated.Series of successful cases
All bare stentsNo cavernoma.