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Management of portal vein thrombosis in liver cirrhosis

Key Points

  • Portal vein thrombosis (PVT) is a fairly common complication of liver cirrhosis; occlusive PVT can be associated with poor prognosis, especially in patients with a prior history of bleeding

  • A randomized controlled trial has shown that anticoagulation is effective for the primary prevention of PVT in liver cirrhosis, and might also improve liver function and survival

  • Further randomized trials with a larger sample size are warranted to confirm these findings

  • Evidence from several case series has demonstrated the efficacy and safety of anticoagulation therapy and a transjugular intrahepatic portosystemic shunt for the management of PVT in liver cirrhosis

  • Future research should aim to weigh the benefits of various treatment modalities against the risks that they will bring and to establish their different timings and indications

Abstract

Portal vein thrombosis (PVT) is a fairly common complication of liver cirrhosis. Importantly, occlusive PVT might influence the prognosis of patients with cirrhosis. Evidence from a randomized controlled trial has shown that anticoagulation can prevent the occurrence of PVT in patients with cirrhosis without prior PVT. Evidence from several case series has also demonstrated that anticoagulation can achieve portal vein recanalization in patients with cirrhosis and PVT. Early initiation of anticoagulation therapy and absence of previous portal hypertensive bleeding might be positively associated with a high rate of portal vein recanalization after anticoagulation. However, the possibility of spontaneous resolution of partial PVT questions the necessity of anticoagulation for the treatment of partial PVT. In addition, a relatively low recanalization rate of complete PVT after anticoagulation therapy suggests its limited usefulness in patients with complete PVT. Successful insertion of a transjugular intrahepatic portosystemic shunt (TIPS) not only recanalizes the thrombosed portal vein, but also relieves the symptomatic portal hypertension. However, the technical difficulty of TIPS potentially limits its widespread application, and the risk and benefits should be fully balanced. Notably, current recommendations regarding the management of PVT in liver cirrhosis are insufficient owing to low-quality evidence.

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Figure 1
Figure 2
Figure 3: Insertion of a TIPS into a large collateral vessel in a patient with complete portal vein obstruction.
Figure 4: Algorithm for the treatment of portal vein thrombosis in liver cirrhosis.

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Acknowledgements

We are indebted to the peer-reviewers' elaborative review and constructive comments for the improvement of our manuscript, especially the adequacy and appropriateness of the treatment algorithm. In addition, we greatly appreciate the help of R. Xia (Educational Technology Center, Fourth Military Medical University, Xi'an, China) in drawing the original schematic graphs of Figure 3b.

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X.Q. researched data for the article, contributed to discussion of content, wrote and reviewed/edited the manuscript. D.F. and G.H. contributed to discussion of content and reviewing/editing the manuscript before submission. All authors contributed equally to this work.

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Correspondence to Guohong Han or Daiming Fan.

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The authors declare no competing financial interests.

Supplementary information

Supplementary Table 1

Common risk factors for portal vein thrombosis in patients with liver cirrhosis (DOCX 47 kb)

Supplementary Table 2

Effect of portal vein thrombosis on the prognosis of cirrhotic patients with bleeding (DOCX 47 kb)

Supplementary Table 3

Incidence and type of TIPS procedure-related complications (DOCX 47 kb)

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Qi, X., Han, G. & Fan, D. Management of portal vein thrombosis in liver cirrhosis. Nat Rev Gastroenterol Hepatol 11, 435–446 (2014). https://doi.org/10.1038/nrgastro.2014.36

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