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Portal Vein Thrombosis and Cirrhosis: The Role of Anticoagulation

  • Management of the Cirrhotic Patient (A Cardenas and N Reau, Section Editors)
  • Published:
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Abstract

Purpose of Review

Anticoagulation has increasingly been reported as treatment of portal vein thrombosis (PVT) in cirrhosis. However, since the role of PVT in cirrhosis outcome is a debated issue, whether performing treatment of PVT in patients with cirrhosis remains a grey area. The aim of this review was to report an update on management of patients with PVT and cirrhosis.

Recent Findings

A review on the management of PVT in cirrhosis, with emphasis on the role of anticoagulation was performed. Numerous studies reported different regimes of anticoagulation (AC) to determine a consistent rate of PV recanalization in cirrhosis. However, all together, data are scant in particular in regard to weight safety of treatment. Furthermore, there are no studies comparing anticoagulation with transjugular intrahepatic portosystemic shunt (TIPS), an alternative treatment for PVT in cirrhosis. Some papers suggest that PVT could worsen both hepatic decompensation and survival rates in patients with cirrhosis, while others report that PVT does not have a significant impact on the outcome of cirrhosis. Therefore, the prognostic value of PVT in cirrhosis remains uncertain. Furthermore, there is no evidence on whether both AC and TIPS really improve survival.

Summary

The indication of anticoagulation as a widespread therapy of PVT in cirrhosis is not acceptable, and decision about such treatment should be personalized. Future studies should evaluate which subgroup of patients with PVT and cirrhosis benefit treatment.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Clinical Practical Guidelines EASL. Vascular diseases of the liver. J Hepatol. 2016;64:179–202.

    Article  Google Scholar 

  2. DeLeve LD, Valla DC, Garcia-Tsao G. Vascular disorders of the liver. Hepatology. 2009;49:1729–64.

    Article  CAS  PubMed  Google Scholar 

  3. Amitrano L, Guardascione MA, Menchise A, Martino R, Scaglione M, Balzano A. Portal vein thrombosis affects prognosis of cirrhotic patients with previous variceal haemorrhage. J Hepatol. 2011;54:S374–5.

    Article  Google Scholar 

  4. Amitrano L, Guardascione MA, Menchise A, Martino R, Scaglione M, Giovine S, et al. Safety and efficacy of anticoagulation therapy with low molecular weight heparin for portal vein thrombosis in patients with liver cirrhosis. J Clin Gastroenterol. 2010;44:448–51.

    CAS  PubMed  Google Scholar 

  5. Bento L, Huerta AR, Pascual C, Rus GP, Catalina V, Yepes I, et al. Antithrombotic therapy in non-neoplastic chronic portal venous thrombosis in cirrhosis: recanalization and liver function evaluation. Blood. 2011;21:118.

    Google Scholar 

  6. Butera G, Simone F, Iaco A, Calvaruso V, DiMarco V, Craxi A. Anticoagulant treatment for not neoplastic portal vein thrombosis in patients with liver cirrhosis and esophageal varices. Dig Liver Dis. 2010;42:S37. 37.

    Article  Google Scholar 

  7. Copaci I, Ismail G, Micu L, Ioanitescu S, Chiriac G. Anticoagulant therapy with sulodexidum for portal vein thrombosis in patients with liver cirrhosis. Hepatology. 2013;58:867A–8A.

    Google Scholar 

  8. Delgado MG, Seijo S, Yepes I, Achecar L, Catalina MV, Garcia-Criado A, et al. Efficacy and safety of anticoagulation on patients with cirrhosis and portal vein thrombosis. Clin Gastroenterol Hepatol. 2012;10:776–83.

    Article  PubMed  Google Scholar 

  9. Dell'Era A, Iannuzzi F, Fabris FM, Fontana P, Reati R, Grillo P, et al. Impact of portal vein thrombosis on the efficacy of endoscopic variceal band ligation. Dig Liver Dis. 2014;46:152–6.

    Article  PubMed  Google Scholar 

  10. Francoz C, Belghiti J, Vilgrain V, Sommacale D, Paradis V, Condat B, et al. Splanchnic vein thrombosis in candidates for liver transplantation: usefulness of screening and anticoagulation. Gut. 2005;54:691–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Garcovich M, Zocco MA, Ainora ME, Annicchiarico BE, Ponziani FR, Cesario V, et al. Clinical outcome of portal vein thrombosis (PVT) in cirrhotic patients: observe or treat? Hepatology. 2011;54:1261A–2A.

    Google Scholar 

  12. Iacob S, Ester C, Popescu I, Gheorghe L. Risk factors for death on the waiting list for liver transplantation in patients with non-malignant portal vein thrombosis. Transplantation. 2014;98:707.

    Google Scholar 

  13. Imamura J, Kimura K, Saeki S, Hayashi S. Danaparoid sodiumwas effective for portal vein thrombosis independent of plasma antithrombin III level. Hepatology. 2011;54:1263A.

    Article  Google Scholar 

  14. Naeshiro N, Aikata H, Hyogo H, Kan H, Fujino H, Kobayashi T, et al. Efficacy and safety of anticoagulant drug, danaparoid sodium, for the treatment of portal vein thrombosis in patients with liver cirrhosis. Hepatol Res. 2015;45:656–62.

    Article  CAS  PubMed  Google Scholar 

  15. Risso A, Stradella D, Martini S, Rizzetto M, Salizzoni M. Liver transplantation in cirrhotic patients with portal vein thrombosis: a single centre experience. Dig Liver Dis. 2014;46:e40.

    Article  Google Scholar 

  16. Senzolo M, Sartori M, Rossetto V, Burra P, Cillo U, Boccagni P, et al. Prospective evaluation of anticoagulation and transjugular intrahepatic portosystemic shunt for the management of portal vein thrombosis in cirrhosis. Liver Int. 2012;32:919–27.

    Article  CAS  PubMed  Google Scholar 

  17. Takatori H, Hayashi T, Sunagozaka H, Arai K, Kitamura K, Kagaya T, et al. Danaparoid sodium monotherapy for portal vein thrombosis in cirrhotic patients is as effective as combination therapy with antithrombin III. Hepatology. 2013;58(4):894A.

    Google Scholar 

  18. Werner KT, Sando S, Carey EJ, Vargas HE, Byrne TJ, Douglas DD, et al. Portal vein thrombosis in patients with end stage liver disease awaiting liver transplantation: outcome of anticoagulation. Dig Dis Sci. 2013;58:1776–80.

    Article  CAS  PubMed  Google Scholar 

  19. Intagliata NM, Henry ZH, Maitland H, Shah NL, Argo CK, Northup PG, Caldwell SH. Direct oral anticoagulants in cirrhosis patients pose similar risks of bleeding when compared to traditional anticoagulation. Dig Dis Sci. 2016;61:1721–7.

    Article  CAS  PubMed  Google Scholar 

  20. Primignani M, Tosetti G, La Mura V. Therapeutic and clinical aspects of portal vein thrombosis in patients with cirrhosis. World J Hepatol. 2015 Dec 18;7(29):2906–12.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Intagliata NM, Maitland H, Northup PG, Caldwell SH. Treating thrombosis in cirrhosis patients with new oral agents: ready or not? Hepatology. 2015 Feb;61(2):738–9.

    Article  CAS  PubMed  Google Scholar 

  22. De Santis A, Moscatelli R, Catalano C, Iannetti A, Gigliotti F, Cristofari F, et al. Systemic thrombolysis of portal vein thrombosis in cirrhotic patients: a pilot study. Dig Liver Dis. 2010;42:451–5.

    Article  CAS  PubMed  Google Scholar 

  23. Cui S, Shu R, Yan S, Wu H, Chen Y, Wang L, Zhu Q. Efficacy and safety on anticoagulation therapy with different doses of enoxaparin for portal vein thrombosis in cirrhotic patients with hepatitis B. Eur J Gastroenterol Hepatol. 2015;27:914–9.

    Article  CAS  PubMed  Google Scholar 

  24. Chung JW, Kim GH, Lee JH, Ok KS, Jang ES, Jeong SH, Kim JW. Safety, efficacy, and response predictors of anticoagulation for the treatment of nomalignant portal-vein thrombosis in patients with cirrhosis: a propensity score analysis. Clinical and Molecular Hepatology. 2014;20:384–91.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Chen H, Liu L, Qi X, He C, Wu FD, Han G. Efficacy and safety of anticoagulation in more advanced portal vein thrombosis in patients with liver cirrhosis. Eur J Gastroenterol Hepatol. 2016;28:82–9.

    Article  PubMed  Google Scholar 

  26. Maruyama H, Takahashi M, Shimada T, Yokosuka O. Emergency anticoagulation treatment for cirrhosis with portal vein thrombosis and acute variceal bleeding. Scand J Gastroenterol. 2012;47:686–91.

    Article  CAS  PubMed  Google Scholar 

  27. De Gottardi A, Trebicka J, Klinger C, Plessier A, Seijo S, Terziroli B, et al. Antithombotic treatment with direct-acting oral anticoagulants in patients with splanchnic vein thrombosis and cirrhosis. Liver International 2017 (IN PRESS).

  28. • Qi X, De Stefano V, Li H, Dai J, Guo X, Fan D. Anticoagulation for the treatment of portal vein thrombosis in liver cirrhosis: a systematic review and meta-analysis of observational studies. European Journal of Internal Medicine. 2015;26:23–9. A systematic review and meta-analysis about anticoagulation for the treatment of portal vein thrombosis in liver cirrhosis: the results overall enlighten on the fact that data about safety of treatment are scanty

    Article  PubMed  Google Scholar 

  29. Senzolo M, Tibbals J, Cholongitas E, Triantos CK, Burroughs AK, Patch D. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation. Aliment Pharmacol Ther. 2006;23:767–75.

    Article  CAS  PubMed  Google Scholar 

  30. Luca A, Miraglia R, Caruso S, Milazzo M, Sapere C, Maruzzelli L, et al. Short- and long-term effects of the transjugular intrahepatic portosystemic shunt on portal vein thrombosis in patients with cirrhosis. Gut. 2011;60:846–52.

    Article  PubMed  Google Scholar 

  31. Perarnau JM, Baju A, d’Alteroche L, Viguier J, Ayoub J. Feasibility and long term evolution of TIPS in cirrhotic patients with portal thrombosis. Eur J Gastroenterol Hepatol. 2010;22:1093–8.

    Article  PubMed  Google Scholar 

  32. Han G, Qi X, He C, Yin Z, Wang J, Xia J, et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosis. J Hepatol. 2011;54:78–88.

    Article  PubMed  Google Scholar 

  33. Wang Z, Jiang MS, Zhang HL, Weng NN, Luo XF, Li X, Yang L. Is post-TIPS anticoagulation therapy necessary in patients with cirrhosis and portal vein thrombosis? A randomized controlled trial. Radiology. 2016;279:943–51.

    Article  PubMed  Google Scholar 

  34. Mancuso A. Management of portal vein thromboses in cirrhosis. Aliment Pharmacol Ther. 2015;41:698.

    Article  CAS  PubMed  Google Scholar 

  35. Mancuso A. Management of portal vein thromboses in cirrhosis: an update. Eur J Gastroenterol Hepatol. 2016;28:739–43.

    Article  CAS  PubMed  Google Scholar 

  36. Mancuso A. Management of portal vein thromboses in cirrhosis: more shadows than lights. Dig Liver Dis. 2017;49:228.

    Article  PubMed  Google Scholar 

  37. Mancuso A. Classification of portal vein thromboses in cirrhosis. Gastroenterology. 2017; (IN PRESS)

  38. • Stine JG, Shah PM, Cornella SL, Rudnick SR, Ghabril MS, Stukenborg GJ, et al. Portal vein thrombosis, mortality and hepatic decompensation in patients with cirrhosis: a meta-analysis. World J Hepatol. 2015;7:2774–80. A meta-analysis suggesting a prognostic value of portal vein thrombosis in the outcome of cirrhosis: however, the results come from only three studies with heterogeneous populations

    Article  PubMed  PubMed Central  Google Scholar 

  39. Englesbe MJ, Kubus J, Muhammad W, Sonnenday CJ, Welling T, Punch JD, et al. Portal vein thrombosis and survival in patients with cirrhosis. Liver Transpl. 2010;16:83–90.

    Article  PubMed  Google Scholar 

  40. John BV, Konjeti R, Aggarwal A, Lopez R, Atreja A, Miller C, et al. Impact of untreated portal vein thrombosis on pre and post liver transplant outcomes in cirrhosis. Ann Hepatol. 2013;12:952–8.

    CAS  PubMed  Google Scholar 

  41. Maruyama H, Okugawa H, Takahashi M, Yokosuka O. De novo portal vein thrombosis in virus-related cirrhosis: predictive factors and long-term outcomes. Am J Gastroenterol. 2013;108:568–74.

    Article  PubMed  Google Scholar 

  42. Nonami T, Yokoyama I, Iwatsuki S, Starzl TE. The incidence of portal vein thrombosis at liver transplantation. Hepatology. 1992;16(5):1195–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Gayowski TJ, Marino IR, Doyle HR, Echeverri L, Mieles L, Todo S, Wagener M, Singh N, Yu VL, Fung JJ, Starzl TE. A high incidence of native portal vein thrombosis in veterans undergoing liver transplantation. J Surg Res. 1996;60:333–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Yerdel MA, Gunson B, Mirza D, Karayalçin K, Olliff S, Buckels J, Mayer D, McMaster P, Pirenne J. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69:1873–81.

    Article  CAS  PubMed  Google Scholar 

  45. Manzanet G, Sanjuán F, Orbis P, López R, Moya A, Juan M, Vila J, Asensi J, Sendra P, Ruíz J, Prieto M, Mir J. Liver transplantation in patients with portal vein thrombosis. Liver Transpl. 2001;7:125–31.

    Article  CAS  PubMed  Google Scholar 

  46. Englesbe MJ, Schaubel DE, Cai S, Guidinger MK, Merion RM. Portal vein thrombosis and liver transplant survival benefit. Liver Transpl. 2010;16:999–1005.

    Article  PubMed  PubMed Central  Google Scholar 

  47. •• Nery F, Chevret S, Condat B, De Raucourt E, Boudaoud L, Rautou PE, et al. Causes and consequences of portal vein thrombosis in 1,243 patients with cirrhosis: results of a longitudinal study. Hepatology. 2015;61:660–7. The main prospective study on portal vein thrombotic incidence in cirrhosis suggesting that the development of portal vein thrombosis does not worsen the outcome of cirrhosis

    Article  CAS  PubMed  Google Scholar 

  48. Qi X, De Stefano V, Senzolo M, Xu H, Mancuso A. Splanchnic vein thrombosis: etiology, diagnosis, and treatment. Gastroenterol Res Pract. 2015;2015:506136.

    PubMed  PubMed Central  Google Scholar 

  49. • Qi X, Dai J, Jia J, Ren W, Yang M, Li H, et al. Association between portal vein thrombosis and survival in non-liver-transplant patients with liver cirrhosis: a systematic review of the literature. Gastroenterol Res Pract. 2015;2015:480842. A systematic review failing to report a meta-analysis because of heterogeneous studies, suggesting that portal vein thrombosis does not worsen the outcome of cirrhosis

    PubMed  PubMed Central  Google Scholar 

  50. Ageno W, Riva N, Schulman S, Beyer-Westendorf J, Bang SM, Senzolo M, et al. Long-term clinical outcomes of splanchnic vein thrombosis. Results of an international registry. JAMA Intern Med. 2015;175(9):1474–80.

    Article  PubMed  Google Scholar 

  51. Luca A, Caruso S, Milazzo M, Marrone G, Mamone G, Crinò F, et al. Natural course of extrahepatic non-malignant partial portal vein thrombosis in patients with cirrhosis. Radiology. 2012;265:124–32.

    Article  PubMed  Google Scholar 

  52. Ghabril M, Agarwal S, Lacerda M, Chalasani N, Kwo P, Tector J. Portal vein thrombosis is a risk factor for poor early outcomes after liver transplantation: analysis of risk factors and outcomes for porta vein thrombosis in waitlisted patients. Transplantation. 2016:126–33.

  53. Villa E, Cammà C, Marietta M, Luongo M, Critelli R, Colopi S, et al. Enoxaparin prevents portal vein thrombosis and liver decompensation in patients with advanced cirrhosis. Gastroenterology. 2012;143:1253–60.

    Article  CAS  PubMed  Google Scholar 

  54. Mancuso A. Cirrhosis development probably arises from chronic micro-vascular ischemia. Med Hypotheses. 2014;82:243–4.

    Article  Google Scholar 

  55. • Mancuso A. The ischemic liver cirrhosis theory and its clinical implications. Med Hypotheses. 2016;94:4–6. A paper reporting the recent ischemic liver cirrhosis theory

    Article  CAS  PubMed  Google Scholar 

  56. Lu H, Liu H, Hu F, Zou L, Luo S, Sun L. Independent association between nonalcoholic fatty liver disease and cardiovascular disease: a systematic review and meta-analysis. Int J Endocrinol. 2013;124958

  57. Mancuso A. Budd-Chiari syndrome management: lights and shadows. World J Hepatol. 2011;3:262–4.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Mancuso A. An update on Management of Budd-Chiari syndrome. Ann Hepatol. 2014;3:323–326. 20.

    Google Scholar 

  59. Mancuso A. An update on management of Budd-Chiari syndrome: the issues of timing and choice of treatment. Eur J Gastroenterol Hepatol. 2015;27:200–3.

    Article  CAS  PubMed  Google Scholar 

  60. Mancuso A. E-letter: treatment of Budd-Chiari syndrome. Blood. 2015;

  61. Simonetto DH, Yang HY, Yin M, De Assuncao TM, Kwon JH, et al. Chronic passive venous congestion drives hepatic fibrogenesis via sinusoidal thrombosis and mechanical forces. Hepatology. 2015;61:649–59.

    Google Scholar 

  62. Mancuso A. Outcome of Budd-Chiari syndrome in Behçet’s syndrome. Semin Arthritis Rheum. 2015;45:e1.

    Article  PubMed  Google Scholar 

  63. Mancuso A. Time to resize the role of liver transplant for Budd-Chiari syndrome. Liver Int. 2015;35:2339.

    Article  PubMed  Google Scholar 

  64. Mancuso A. The target of TIPS for Budd-Chiari syndrome should be avoiding liver transplantation. Aliment Pharmacol Ther. 2014;39:1342.

    Article  CAS  PubMed  Google Scholar 

  65. Mancuso A. TIPS for Budd-Chiari syndrome: time to anticipate treatment. Liver Int. 2014;7:e325.

    Article  Google Scholar 

  66. Mancuso A. Budd-Chiari syndrome management: timing of treatment is an open issue. Hepatology. 2014;59:1213.

    Article  PubMed  Google Scholar 

  67. Mancuso A. Management of Budd-Chiari syndrome in children: same debated issues as in adults. Eur J Gastroenterol Hepatol. 2015;27:107–8.

    Article  PubMed  Google Scholar 

  68. Mancuso A, Fung K, Mela M, Tibballs J, Watkinson A, Burroughs AK, et al. TIPS for acute and chronic Budd-Chiari syndrome: a single-centre experience. J Hepatol. 2003;38:751–4.

    Article  PubMed  Google Scholar 

  69. Mancuso A, Watkinson A, Tibballs J, Patch D, Burroughs AK. Budd-Chiari syndrome with portal, splenic, and superior mesenteric vein thrombosis treated with TIPS: who dares wins. Gut. 2003;52:438.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  70. Mancuso A, Martinelli L, De Carlis L, Rampoldi AG, Magenta G, Cannata A, et al. A caval homograft for Budd-Chiari syndrome due to inferior vena cava obstruction. World J Hepatol. 2013;27:292–5.

    Article  Google Scholar 

  71. Mancuso A. Why treatments of hepatitis C virus are less effective in cirrhosis. Aliment Pharmacol Ther. 2015;41:707.

    Article  CAS  PubMed  Google Scholar 

  72. Cerini F, Vilaseca M, Lafoz E, García-Irigoyen O, García-Calderó H, Tripathi DM, et al. Enoxaparin reduces hepatic vascular resistance and portal pressure in cirrhotic rats. J Hepatol. 2016;64:834–42.

    Article  CAS  PubMed  Google Scholar 

  73. Klein S, Rick J, Lehmann J, Schierwagen R, Schierwagen IG, Verbeke L, Hittatiya K, et al. Janus-kinase-2 could relate directly to portal hypertension and to complications in rodent and human cirrhosis. Gut. 2017;66:145–55.

    Article  PubMed  Google Scholar 

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  1. Medicina Interna 1, ARNAS Civico Di Cristina Benfratelli, Piazzale Leotta 4, 90100, Palermo, Italy

    Andrea Mancuso

  2. Epatologia e Gastroenterologia, Ospedale Niguarda Ca’ Granda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy

    Andrea Mancuso

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Mancuso, A. Portal Vein Thrombosis and Cirrhosis: The Role of Anticoagulation. Curr Hepatology Rep 16, 158–163 (2017). https://doi.org/10.1007/s11901-017-0344-z

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