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Anticoagulation in Cirrhosis and Portal Vein Thrombosis Is Safe and Improves Prognosis in Advanced Cirrhosis

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Abstract

Background

The role of portal vein thrombosis (PVT) in the natural history of cirrhosis is controversial.

Aims

We analyzed the safety and effect of anticoagulant therapy (AT) on PVT recanalization and orthotopic liver transplant (OLT)-free survival.

Methods

Eighty consecutive patients from a prospective registry of cirrhosis and non-tumoral PVT at a tertiary center were analyzed. AT effect on PVT recanalization and OLT-free survival was determined by time-dependent Cox regression analysis.

Results

Average MELD score was 15 ± 7. Portal hypertension-related complications at PVT diagnosis were present in 65 (81.3%) patients. Isolated portal vein trunk/branch thrombosis was present in 53 (66.3%) patients. AT was started in 37 patients. AT was stopped in 17 (45.9%) patients, in 4 (10.8%) due to bleeding events. No variceal bleeding occurred while on AT. Anticoagulation was restarted in 6/17 (35.2%) patients due to rethrombosis. In 67 patients with adequate follow-up imaging, AT significantly increased the rate of PVT recanalization compared with those who did not receive anticoagulation [51.4% (18/35) vs 6/32 (18.8%), p = 0.005]. OLT-free survival after a median follow-up of 25 (1–146) months was 32 (40%). Although there was no significant effect of AT on overall OLT-free survival, OLT-free survival was higher among patients with MELD ≥ 15 receiving AT compared to those who did not (p = 0.011). Baseline MELD at PVT detection independently predicted PVT recanalization (HR 1.11, 95% CI 1.01–1.21, p = 0.027) and mortality/OLT (HR 1.12, 95% CI 1.05–1.19, p < 0.001).

Conclusions

Although AT did not improve overall OLT-free survival, it was associated with higher survival in advanced cirrhosis. Anticoagulation increased PVT recanalization and should be maintained after PVT recanalization to avoid rethrombosis.

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Abbreviations

PVT:

Portal vein thrombosis

US:

Ultrasound

OLT:

Orthotopic liver transplantation

LMWH:

Low molecular weight heparin

AT:

Anticoagulant therapy

HCC:

Hepatocellular carcinoma

CT:

Computerized tomography

MRI:

Magnetic resonance imaging

TIPS:

Transjugular intrahepatic portosystemic shunt

KM:

Kaplan–Meier

MELD:

Model for End-Stage Liver Disease

GOV1:

Gastroesophageal varices type 1

IGV:

Isolated gastric varices

GOV2:

Gastroesophageal varices type 2

UGIB:

Upper gastrointestinal bleeding

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Acknowledgments

We would like to express our sincere thanks to Professors Dominique Valla and Juan Carlos García-Pagán for their constructive comments and expert advice in preparation of this manuscript, Dr. Teresa Rodrigues for her valuable support and advice regarding statistical analysis of this manuscript, and Drs. Filipe Calinas, Joana Saiote, and Mario Silva for their help in data collection in some patients.

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Authors and Affiliations

  1. Serviço De Gastrenterologia e Hepatologia, Hospital de Santa Maria – Centro Hospitalar Universitário Lisboa Norte, Avenida Egas Moniz, 1649-035, Lisbon, Portugal

    Carlos Noronha Ferreira, Daniela Reis, Helena Cortez-Pinto, Rui Tato Marinho, Paula Alexandrino, Fátima Serejo, Margarida Sobral Dias, Paula Ferreira, Mariana Vasconcelos, Filipe Damião, Leonor Xavier Brito, Cilenia Baldaia, Narcisa Fatela, Fernando Ramalho & José Velosa

  2. Serviço De Imagiologia, Hospital de Santa Maria – Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal

    Afonso Gonçalves, Sónia Palma, Inês Leite & Tiago Rodrigues

  3. Serviço De Medicina II, Hospital De Santa Maria - Centro Hospitalar Lisboa, Lisbon, Portugal

    Ana Júlia Pedro

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  1. Carlos Noronha Ferreira
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Contributions

Carlos Noronha Ferreira, MD, was involved in study design, patient inclusion, data collection, data analysis and preparation, and critical review of the manuscript. Daniela Reis, MD, performed data collection and critical review of the manuscript. Helena Cortez-Pinto, PhD, Rui Tato Marinho, PhD, Afonso Gonçalves, MD, Sónia Palma, MD, Inês Leite, MD, Tiago Rodrigues, MD, Ana Júlia Pedro, MD, Paula Alexandrino, MD, Fátima Serejo, PhD, Margarida Sobral Dias, MD, Paula Ferreira, MD, Mariana Vasconcelos, MD, Filipe Damião, MD, Leonor Xavier Brito, MD, Cilenia Baldaia, MD, Narcisa Fatela, MD, Fernando Ramalho, PhD, José Velosa, PhD, were all involved in patient inclusion and critical review of the manuscript.

Corresponding author

Correspondence to Carlos Noronha Ferreira.

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Noronha Ferreira, C., Reis, D., Cortez-Pinto, H. et al. Anticoagulation in Cirrhosis and Portal Vein Thrombosis Is Safe and Improves Prognosis in Advanced Cirrhosis. Dig Dis Sci 64, 2671–2683 (2019). https://doi.org/10.1007/s10620-019-05572-z

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