Application of ultrasonography-elastography score to suspect porto-sinusoidal vascular disease in patients with portal vein thrombosis

Background:Porto-sinusoidal vascular disease(PSVD)and portal vein thrombosis(PVT)are causes of portal hypertension characterized respectively by an intrahepatic and a pre-hepatic obstacle to the flow in the portal system.As PVT may be a consequence of PSVD,in PVT patients at presentation,a pre-existing PSVD should be suspected.In these patients the identification of an underlying PSVD would have relevant implication regarding follow-up and therapeutic management,but it could be challenging.In this setting ultrasonography may be valuable in differential diagnosis.The aim of the study was to use ultrasonography to identify parameters to discriminate between PSVD and“pure”PVT and then to suspect PVT secondary to a pre-existing PSVD.Methods:Fifty-three patients with histologically proven PSVD and forty-eight patients affected by chronic PVT were enrolled and submitted to abdominal ultrasonography with elastography by acoustic radiation force impulse(ARFI).Results:ARFI was higher and superior mesenteric vein(SMV)diameter was wider in PSVD patients than in PVT patients.Thus,a prognostic score was obtained as linear combinations of the two parameters with a good discrimination capacity between PSVD and PVT(the area under the curve=0.780;95%confidence interval:0.690-0.869).Conclusions:A score based on ARFI and SMV diameter may be useful to suspect an underlying PSVD in patients with PVT and to identify a subgroup of patients to be submitted to liver biopsy.

Inhibiting MMP13 Attenuates Deep Vein Thrombosis in a Mouse Model by Reducing the Expression of Pdpn

Objective:Matrix metalloproteinase 13(MMP13)is an extracellular matrix protease that affects the progression of atherosclerotic plaques and arterial thrombi by degrading collagens,modifying protein structures and regulating inflammatory responses,but its role in deep vein thrombosis(DVT)has not been determined.The purpose of this study was to investigate the potential effects of MMP13 and MMP13-related genes on the formation of DVT.Methods:We altered the expression level of MMP13 in vivo and conducted a transcriptome study to examine the expression and relationship between MMP13 and MMP13-related genes in a mouse model of DVT.After screening genes possibly related to MMP13 in DVT mice,the expression levels of candidate genes in human umbilical vein endothelial cells(HUVECs)and the venous wall were evaluated.The effect of MMP13 on platelet aggregation in HUVECs was investigated in vitro.Results:Among the differentially expressed genes,interleukin 1 beta,podoplanin(Pdpn),and factor VIII von Willebrand factor(F8VWF)were selected for analysis in mice.When MMP13 was inhibited,the expression level of PDPN decreased significantly in vitro.In HUVECs,overexpression of MMP13 led to an increase in the expression level of PDPN and induced platelet aggregation,while transfection of PDPN-siRNA weakened the ability of MMP13 to increase platelet aggregation.Conclusions:Inhibiting the expression of MMP13 could reduce the burden of DVT in mice.The mechanism involves downregulating the expression of Pdpn through MMP13,which could provide a novel gene target for DVT diagnosis and treatment.

Predictive model for non-malignant portal vein thrombosis associated with cirrhosis based on inflammatory biomarkers

BACKGROUND Portal vein thrombosis(PVT),a complication of liver cirrhosis,is a major public health concern.PVT prediction is the most effective method for PVT diagnosis and treatment.AIM To develop and validate a nomogram and network calculator based on clinical indicators to predict PVT in patients with cirrhosis.METHODS Patients with cirrhosis hospitalized between January 2016 and December 2021 at the First Hospital of Lanzhou University were screened and 643 patients with cirrhosis who met the eligibility criteria were retrieved.Following a 1:1 propensity score matching 572 patients with cirrhosis were screened,and relevant clinical data were collected.PVT risk factors were identified using the least absolute shrinkage and selection operator(LASSO)and multivariate logistic regression analysis.Variance inflation factors and correlation matrix plots were used to analyze multicollinearity among the variables.A nomogram was constructed to predict the probability of PVT based on independent risk factors for PVT,and its predictive performance was verified using a receiver operating characteristic curve(ROC),calibration curves,and decision curve analysis(DCA).Finally,a network calculator was constructed based on the nomograms.RESULTS This study enrolled 286 cirrhosis patients with PVT and 286 without PVT.LASSO analysis revealed 13 variables as strongly associated with PVT occurrence.Multivariate logistic regression analysis revealed nine indicators as independent PVT risk factors,including etiology,ascites,gastroesophageal varices,platelet count,D-dimer,portal vein diameter,portal vein velocity,aspartate transaminase to neutrophil ratio index,and platelet-to-lymphocyte ratio.LASSO and correlation matrix plot results revealed no significant multicollinearity or correlation among the variables.A nomogram was constructed based on the screened independent risk factors.The nomogram had excellent predictive performance,with an area under the ROC curve of 0.821 and 0.829 in the training and testing groups,respectively.Calibration curves and DCA revealed its good clinical performance.Finally,the optimal cutoff value for the total nomogram score was 0.513.The sensitivity and specificity of the optimal cutoff values were 0.822 and 0.706,respectively.CONCLUSION A nomogram for predicting PVT occurrence was successfully developed and validated,and a network calculator was constructed.This can enable clinicians to rapidly and easily identify high PVT risk groups.

Simultaneous portal vein thrombosis and splenic vein thrombosis in a COVID-19 patient:A case report and review of literature

BACKGROUND It is well-described that the coronavirus disease 2019(COVID-19)infection is associated with an increased risk of thrombotic complications.While there have been many cases of pulmonary emboli and deep vein thrombosis in these patients,reports of COVID-19 associated portal vein thrombosis(PVT)have been uncommon.We present a unique case of concomitant PVT and splenic artery thrombosis in a COVID-19 patient.CASE SUMMARY A 77-year-old-male with no history of liver disease presented with three days of left-sided abdominal pain.One week earlier,the patient was diagnosed with mildly symptomatic COVID-19 and was treated with nirmatrelvir/ritonavir.Physical exam revealed mild right and left lower quadrant tenderness,but was otherwise unremarkable.Significant laboratory findings included white blood cell count 12.5 K/μL,total bilirubin 1.6 mg/dL,aminoaspartate transferase 40 U/L,and alanine aminotransferase 61 U/L.Computed tomography of the abdomen and pelvis revealed acute PVT with thrombus extending from the distal portion of the main portal vein into the right and left branches.Also noted was a thrombus within the distal portion of the splenic artery with resulting splenic infarct.Hypercoagulable workup including prothrombin gene analysis,factor V Leiden,cardiolipin antibody,and JAK2 mutation were all negative.Anticoagulation with enoxaparin was initiated,and the patient’s pain improved.He was discharged on apixaban.CONCLUSION It is quite uncommon for PVT to present simultaneously with an arterial thrombotic occlusion,as in the case of our patient.Unusual thrombotic manifestations are classically linked to hypercoagulable states including malignancy and hereditary and autoimmune disorders.Viral infections such as Epstein-Barr virus,cytomegalovirus,viral hepatitis,and COVID-19 have all been found to increase the risk of splanchnic venous occlusions,including PVT.In our patient,prompt abdominal imaging led to early detection of thrombus,early treatment,and an excellent outcome.This case is unique in that it is the second known case within the literature of simultaneous PVT and splenic artery thrombosis in a COVID-19 patient.

Current concepts in the management of non-cirrhotic non-malignant portal vein thrombosis

Non-cirrhotic non-malignant portal vein thrombosis(NCPVT)is an uncommon condition characterised by thrombosis of the portal vein,with or without extension into other mesenteric veins,in the absence of cirrhosis or intra-abdominal malignancy.Complications can include intestinal infarction,variceal bleeding and portal biliopathy.In this article,we address current concepts in the management of NCPVT including identification of risk factors,classification and treatment,and review the latest evidence on medical and interventional management options.

Predictors of portal vein thrombosis after splenectomy in patients with cirrhosis

BACKGROUND Portal vein thrombosis(PVT)is a commonthsn complication after splenectomy in patients with cirrhosis.However,the predictors of postoperative PVT are not known.AIM To investigate the predictors of PVT after splenectomy in patient with cirrhosis.METHODS A total of 45 patients with cirrhosis who underwent splenectomy were consecutively enrolled from January 2017 to December 2018.The incidence of PVT at 1 months,3 months,and 12 months after splenectomy in patients with cirrhosis was observed.The hematological indicators,biochemical and coagulation parameters,and imaging features were recorded at baseline and at each observation point.The univariable,multivariable,receiver operating characteristic curve and timedependent curve analyses were performed.RESULTS The cumulative incidence of PVT was 40.0%,46.6%,and 48.9%at 1 months,3 months,and 12 months after splenectomy.Multivariable analysis showed that portal vein diameter(PVD)≥14.5 mm and monthsdel end-stage liver disease(MELD)score>10 were independent predictors of PVT at 1 months,3 months,and 12 months after splenectomy(P<0.05).Time-dependent curve showed that the cumulative incidence of PVT was significantly different between patients with MELD score≤10 and>10(P<0.05).In addition,the cumulative incidence of PVT in the PVD≥14.5 mm group was significantly higher than that in the PVD<14.5 mm group(P<0.05).CONCLUSION Wider PVD and MELD score>10 were independent predictors of PVT at 1 months,3 months,and 12 months after splenectomy in patient with cirrhosis.

Upper extremity deep vein thrombosis:An intensivist’s perspective

Upper extremity deep vein thrombosis(UEDVT)is less common than lower extremity DVT but is a cause of significant morbidity and mortality in intensive care unit patients.Increasing cancer incidence,prolonged life expectancy and increasing use of intravascular catheters and devices has led to an increased incidence of UEDVT.It is also associated with high rates of complications like pulmonary embolism,post-thrombotic syndrome and recurrent thrombosis.Clinical prediction scores and D-dimer may not be as useful in identifying UEDVT;hence,a high suspicion index is required for diagnosis.Doppler ultrasound is commonly employed for diagnosis,but other tests like computed tomography and magnetic resonance imaging venography may also be required in some patients.Contrast venography is rarely used in patients with clinical and ultrasound findings discrepancies.Anticoagulant therapy alone is sufficient in most patients,and thrombolysis and surgical decompression is seldom indicated.The outcome depends on the cause and underlying comorbidities.

Direct oral anticoagulants for the treatment of splanchnic vein thrombosis:A state of art

Splanchnic vein thrombosis(SVT)is a manifestation of venous thromboembolism in an unusual site.Portal,mesenteric,and splenic veins are the most common vessels involved in SVT which occurs mainly in patients with liver cirrhosis,although non-cirrhotic patients could be affected as well.Thrombosis of hepatic veins,also known as Budd-Chiari syndrome,is another manifestation of SVT.Prompt diagnosis and intervention are mandatory in order to increase the recalization rate and reduce the risk of thrombus progression and hypertensive complications.Traditional anticoagulation with heparin and vitamin-K antagonists is the treatment of choice in these cases.However,recent studies have shown promising results on the efficacy and safety of direct oral anticoagulants(DOACs)in this setting.Available results are mainly based on retrospective studies with small sample size,but first clinical trials have been published in the last years.This manuscript aims to provide an updated overview of the current evidence regarding the role of DOACs for SVT in both cirrhotic and non-cirrhotic patients.

Therapeutic anticoagulation for splanchnic vein thrombosis in acute pancreatitis: A national survey and case-vignette study

BACKGROUND Splanchnic vein thrombosis(SVT)is a major complication of moderate and severe acute pancreatitis.There is no consensus on whether therapeutic anticoagulation should be started in patients with acute pancreatitis and SVT.AIM To gain insight into current opinions and clinical decision making of pancreatologists regarding SVT in acute pancreatitis.METHODS A total of 139 pancreatologists of the Dutch Pancreatitis Study Group and Dutch Pancreatic Cancer Group were approached to complete an online survey and case vignette survey.The threshold to assume group agreement was set at 75%.RESULTS The response rate was 67%(n=93).Seventy-one pancreatologists(77%)regularly prescribed therapeutic anticoagulation in case of SVT,and 12 pancreatologists(13%)for narrowing of splanchnic vein lumen.The most common reason to treat SVT was to avoid complications(87%).Acute thrombosis was the most important factor to prescribe therapeutic anticoagulation(90%).Portal vein thrombosis was chosen as the most preferred location to initiate therapeutic anticoagulation(76%)and splenic vein thrombosis as the least preferred location(86%).The preferred initial agent was low molecular weight heparin(LMWH;87%).In the case vignettes,therapeutic anticoagulation was prescribed for acute portal vein thrombosis,with or without suspected infected necrosis(82%and 90%),and thrombus progression(88%).Agreement was lacking regarding the selection and duration of long-term anticoagulation,the indication for thrombophilia testing and upper endoscopy,and about whether risk of bleeding is a major barrier for therapeutic anticoagulation.CONCLUSION In this national survey,the pancreatologists seemed to agree on the use of therapeutic anticoagulation,using LMWH in the acute phase,for acute portal thrombosis and in the case of thrombus progression,irrespective of the presence of infected necrosis.

Analysis of risk factors for postoperative deep vein thrombosis after craniotomy and nomogram model construction

BACKGROUND Deep vein thrombosis(DVT)of the lower extremity is one of the most common postoperative complications,especially after craniocerebral surgery.DVT may lead to pulmonary embolism,which has a devastating impact on patient prognosis.This study aimed to investigate the incidence and risk factors of DVT in the lower limbs following craniocerebral surgery.AIM To identify independent risk factors for the development of postoperative DVT and to develop an effective risk prediction model.METHODS The demographic and clinical data of 283 patients who underwent craniocerebral surgery between December 2021 and December 2022 were retrospectively analyzed.The independent risk factors for lower extremity DVT were identified by univariate and multivariate analyses.A nomogram was created to predict the likelihood of lower extremity DVT in patients who had undergone craniocerebral surgery.The efficacy of the prediction model was determined by receiver operating characteristic curve using the probability of lower extremity DVT for each sample.RESULTS Among all patients included in the analysis,47.7%developed lower extremity DVT following craniocerebral surgery.The risk of postoperative DVT was higher in those with a longer operative time,and patients with intraoperative intermittent pneumatic compression were less likely to develop postoperative DVT.CONCLUSION The incidence of lower extremity DVT following craniocerebral surgery is significant,highlighting the importance of identifying independent risk factors.Interventions such as the use of intermittent pneumatic compression during surgery may prevent the formation of postoperative DVT.

Postpartum ovarian vein thrombosis after cesarean section and vaginal delivery:Two case reports

BACKGROUND Postpartum ovarian vein thrombosis(POVT)is a rare puerperal complication.It is easily missed or misdiagnosed due to its insidious onset and lack of specific clinical symptoms and signs.This paper reports two patients who developed right ovarian vein thrombosis after cesarean section and vaginal delivery,respectively.CASE SUMMARY Case 1 was a 32-year-old female who underwent a cesarean section in labor at 40 wk of gestation due to fetal distress.The patient was persistently febrile after the operation and escalated antibiotic treatment was ineffective.POVT was diagnosed by abdominal computed tomography(CT)and was treated by increasing the dose of low molecular weight heparin(LMWH).Case 2 was a 21-year-old female with a spontaneous vaginal delivery at 39 wk of gestation.The patient developed fever and abdominal pain 3 days after delivery.POVT was promptly identified by abdominal CT,and the condition was quickly controlled after treatment with LMWH and antibiotics.CONCLUSION These two cases occurred after cesarean section and vaginal delivery,respectively.The diagnosis was mainly based on imaging examination due to the unspecific clinical symptoms and signs,the CT scan provided an especially high diagnostic value.Comparing these two cases,escalating antibiotics alone did not provide significant therapeutic benefit,but the early escalation of anticoagulant dosage seemed to shorten the disease course.Therefore,early diagnosis by CT followed by aggressive anticoagulation might have a positive effect on improving the prognosis of the disease.

Wandering spleen torsion with portal vein thrombosis:A case report

BACKGROUND Wandering spleen is rare clinically.It is characterized by displacement of the spleen in the abdominal and pelvic cavities and can have congenital or acquired causes.Wandering spleen involves serious complications,such as spleen torsion.The clinical symptoms range from asymptomatic abdominal mass to acute abdominal pain.Surgery is required after diagnosis.Cases of wandering spleen torsion with portal vein thrombosis(PVT)are rare.There is no report on how to eliminate PVT in such cases.CASE SUMMARY Ultrasound and computed tomography revealed a diagnosis of wandering spleen torsion with PVT in a 31-year-old woman with a history of childbirth 16 mo previously who received emergency treatment for upper abdominal pain.She recovered well after splenectomy and portal vein thrombectomy combined with continuous anticoagulation,and the PVT disappeared.CONCLUSION Rare and nonspecific conditions,such as wandering splenic torsion with PVT,must be diagnosed and treated early.Patients with complete splenic infarction require splenectomy.Anticoagulation therapy and individualized management for PVT is feasible.

Outcome of Patients with Lower Limbs Deep Vein Thrombosis at the University Hospital of Brazzaville (The Republic of the Congo)

The aim of this study was to describe the characteristics of patients with deep vein thrombosis (DVT) of the pelvic limbs at the time of diagnosis, and their course after hospitalization, in order to improve the management of DVT in our context. This was a descriptive longitudinal study, based on cases of deep vein thrombosis recorded between 1 January 2015 and 30 September 2018, in the cardiology and internal medicine department of the Brazzaville University Hospital Centre. During the study period, 4678 patients were hospitalized, including 52 with DVT. Thirty-three were reassessed. The frequency of DVT was 1.1% and the average hospitalization rate was 13.9 cases/year. The 33 patients were divided into 20 women and 13 men (sex ratio: 0.65). The mean age of the patients was 51.4 ± 17.8 years (extremes: 16 and 85 years). The main aetiological factors were cancer (19.1%), sickle cell disease (3%) and HIV immunosuppression (3%). The predominant risk factors were: prolonged immobilization (42.9%), pregnancy, long travel and obesity in the same number of cases (n = 3, i.e. 14.2%). The DVT involved the left pelvic limb in 75.8% of cases. Anticoagulants were administered in all patients, and compression stockings were worn in 97% of cases. The mean time to re-evaluation was 10.9 ± 9.4 months (extremes: three and 35 months). The mean measurements of the limb where the thrombosis had occurred at diagnosis and reassessment showed a significant difference. Venous Doppler showed compressible veins (60.6%), varicosities (36.3%), incompressible veins (30.3%) and thrombus (21.2%). Complications were: post-phlebitic disease (42.4%), death (21.2%), pulmonary embolism (18.2%), recurrence (18.2%). The DVT remains relatively rare, and its conventional therapeutic management is satisfactory. Systematic venous Doppler ultrasound reassessment should enable patients at risk of recurrence to be identified.

Ovarian Vein Thrombosis, Critical Diagnosis at Al-Hasahisa Obstetrics & Gynecology Teaching Hospital in Geziera State, Sudan

Ovarian vein thrombosis (OVT) is a rare thrombotic condition commonly attributed to the puerperium. The complications of OVT can be significant, and diagnosis relies on a high clinical index of suspicion. It can occur with lower quadrant pain that may mimic a surgical abdomen, especially in the setting of recent pregnancy, abdominal surgery, inflammatory disease, or malignancy. Diagnosis can be made with confidence using ultrasound, computed tomography, or magnetic resonance imaging. Management of OVT is particularly important in postpartum patients, with anticoagulation therapy being the treatment of choice.

Analysis and Literature Review of Deep Vein Thrombosis Related Phlegmasia Cerulea Dolens Diagnosis in Critically Patients

Goal: The purpose of this research is to analyze the clinical characteristics, diagnosis, treatment, and prognosis of critical care patients with phlegmasia cerulea dolens (PCD) caused by deep vein thrombosis. Our goal is to improve both awareness and early diagnosis and treatment of rare clinical diseases. Furthermore, we aim to examine advancements in the diagnosis and treatment of deep vein thrombosis. Method: The clinical information of patients with PCD received in 2022 was subject to retrospective analysis. The author conducted a search of 191 publications with a focus on PCD, from January 2010 to July 2022, from databases such as the China National Knowledge Infrastructure (CNKI), Wanfang Data, PubMed, etc. The results were used to summarize the examinations, diagnostic criteria, and treatment progress of PCD patients. Additionally, the author conducted another search using keywords such as “Venous thromboembolism” and “Anticoagulant drugs” to summarize research progress in anticoagulant drugs and the treatment of VTE. The search was limited to relevant. Outcome: Six months prior to admission, the patient, a 68-year-old female, developed sunken edema and cyanosis in both her lower extremities and was diagnosed with lower extremity deep vein thrombosis complicated by PCD, lower extremity ischemic necrosis, and septicemia. This diagnosis was made using a combination of CT and lower extremity vascular ultrasound-related examinations, as well as a significantly elevated D-dimer value. Despite active treatment and aggressive measures, such as anti-infection, organ function maintenance, anticoagulation, and improvement of microcirculatory disorders, the patient’s family declined corresponding surgical treatment and interventional surgery for the lower extremity due to objective factors, and the patient ultimately succumbed to her illness. The clinical characteristics of this patient were similar to those of the 14 cases of PCD reported by Xie Fei et al. in 2022. Conclusion: For patients with malignancy, it is crucial to start anticoagulation and physical prevention of DVT early on. Patients with DVT complicated by PCD have a variety of surgical options available to them, including surgical embolization or PMT (percutaneous mechanical thrombus ablation), CDT (catheter contact thrombolysis), and fascial ventriculotomy decompression [1]. Additionally, it may be necessary to place an inferior venous filter. Although the incidence of this disease is low accounting for approximately 5% of all patients with iliofemoral deep vein thrombosis [2], the prognosis is poor, as the mortality rate can reach up to 40% - 60% due to venous gangrene, with an overall mortality rate of 20% - 40% [3]. To increase the survival rate, it is important to diagnose and treat this disease as early as possible.

Portal vein thrombosis:Insight into physiopathology,diagnosis,and treatment

Portal vein thrombosis (PVT) is a relatively common complication in patients with liver cirrhosis, but might also occur in absence of an overt liver disease. Several causes, either local or systemic, might play an important role in PVT pathogenesis. Frequently, more than one risk factor could be identified; however, occasionally no single factor is discernable. Clinical examination, laboratory investigations, and imaging are helpful to provide a quick diagnosis, as prompt treatment might greatly affect a patient's outcome. In this review, we analyze the physiopathological mechanisms of PVT development, together with the hemodynamic and functional alterations related to this condition. Moreover, we describe the principal factors most frequently involved in PVT development and the recent knowledge concerning diagnostic and therapeutic procedures. Finally, we analyze the implications of PVT in the setting of liver transplantation and its possible influence on patients' future prognoses.

Clinical outcomes of transcatheter selective superior mesenteric artery urokinase infusion therapy vs transjugular intrahepatic portosystemic shunt in patients with cirrhosis and acute portal vein thrombosis

AIM To compare the outcomes of transcatheter superior mesenteric artery(SMA) urokinase infusion and transjugular intrahepatic portosystemic shunt(TIPS) for acute portal vein thrombosis(PVT) in cirrhosis.METHODS From January 2013 to December 2014, patients with liver cirrhosis and acute symptomatic PVT who met the inclusion criteria were randomly assigned to either an SMA group or a TIPS group. The two groups accepted transcatheter selective SMA urokinase infusion therapyand TIPS, respectively. The total follow-up time was24 mo. The primary outcome measure was the change in portal vein patency status which was evaluated by angio-computed tomography or Doppler ultrasound.Secondary outcomes were rebleeding and hepatic encephalopathy.RESULTS A total of 40 patients were enrolled, with 20 assigned to the SMA group and 20 to the TIPS group. The symptoms of all patients in the two groups improved within 48 h. PVT was improved in 17(85%) patients in the SMA group and 14(70%) patients in the TIPS group. The main portal vein(MPV) thrombosis was significantly reduced in both groups(P < 0.001), and there was no significant difference between them(P= 0.304). In the SMA group, superior mesenteric vein(SMV) thrombosis and splenic vein(SV) thrombosis were significantly reduced(P = 0.048 and P = 0.02),which did not occur in the TIPS group. At 6-, 12-,and 24-mo follow-up, in the SMA group and the TIPS group, the cumulative rates free of the first episode of rebleeding were 80%, 65%, and 45% vs 90%, 80%,and 60%, respectively(P = 0.320); the cumulative rates free of the first episode of hepatic encephalopathy were 85%, 80%, and 65% vs 50%, 40%, and 35%,respectively(P = 0.022).CONCLUSION Transcatheter selective SMA urokinase infusion and TIPS are safe and effective for acute symptomatic PVT in cirrhosis.

Risk factors and clinical characteristics of portal vein thrombosis after splenectomy in patients with liver cirrhosis

BACKGROUND:Portal vein thrombosis(PVT) is a potential lethal complication and may have negative influence on the prognosis after splenectomy in patients with liver cirrhosis.Prevention and timely detection of PVT are quite significant.There is a lack of knowledge about the clinical features and risk factors of PVT.Our study aimed to investigate the risk factors and clinical characteristics of PVT in order to figure out the high-risk individuals.METHODS:We collected the clinical data of 472 consecutive patients with non-neoplastic liver cirrhosis who had undergone splenectomy from January 2008 to December 2010 in our institution.Clinical and surgical characteristics of patients who developed PVT postoperatively and those who did not develop PVT were compared.Univariate and multivariate analyses of risk factors of PVT were performed.The mortality and rebleeding rate of the patients were also evaluated.RESULTS:Of the 472 patients,52 were excluded from the study.PVT developed in 71(71/420,16.9%) patients.Multivariate analysis revealed that wider preoperative portal vein diameter,postoperative thrombocytosis,prolonged prothrombin time and periesophagogastric devascularization were significantly correlated with PVT development [odds ratio(OR):5.701,2.807,1.850 and 2.090,respectively].The incidence of PVT in patients who took antiplatelet drugs was not lower than that in those who did not.Follow-up showed that patients in the PVT group had a tendency towards reduced overall survival but it was not statistically significant.Gastrointestinal bleeding occurred more often in the PVT group than that in the non-PVT group(P=0.044).CONCLUSIONS:Wider preoperative portal vein diameter,postoperative thrombocytosis,prolonged prothrombin time and periesophagogastric devascularization are independent risk factors of PVT.PVT is related with higher risk of postoperative gastrointestinal hemorrhage but has no significant impact on the overall survival.

Liver transplant recipients with portal vein thrombosis:a single center retrospective study

BACKGROUND: Portal vein thrombosis (PVT) used to be a contraindication for liver transplantation (LT). This obstacle has been delt with following the improvement of LT-related techniques and therapeutic approaches to thrombosis. But the effect of PVT on LT outcomes is still controversial. We reviewed retrospectively the outcome of LT patients with PVT as well as risk factors and surgical management according to PVT grades. METHODS: A total of 465 adult LTs were performed from December 2002 through December 2006. Operative findings and the result of preoperative ultrasonography and imaging were reviewed for PVT grading (Yerdel grading). Comparison of risk factors, variables associated with perioperative period and prognosis between recipients with and without PVT is based on the grades. RESULTS: In the 465 LTs, 42 were operatively confirmed to have PVT (9.0%) (19 recipients with grade I, 14 with grade 2, 7 with grade 3, and 2 with grade 4). Increased age and treatment of portal hypertension were associated with PVT. Grade 1 or 2 PVT was treated by direct anastomosis or single thrombectomy. In grade 3 PVT patients, the donor PV was directly anastomosed to the dilated branch of the recipient portal venous system or to the distal open superior mesenteric vein through an interposition vein graft if needed. Grade 4 PVT was managed by our modified cavoportal hemitransposition technique. The comparison between PVT patients and controls showed no significant difference in operative duration and blood transfusion (P > 0.05). The flow rate of the PV was lower in the PVT patients (48.881 +/- 12.788 cm/s) than in the controls (57.172 +/- 21.715 cm/s, P < 0.05). The PVT patients had such postoperative complications as renal failure and PV rethrombosis (P < 0.05). The 1-year survival rates in PVT and non-PVT patients were 78.6% and 76.4% respectively (P > 0.05); the 3-year survival rates were 58.8% and 56.4% respectively (P > 0.05). CONCLUSIONS: PVT is not contraindicated for LT if it is graded. PVT recipients may have post-transplantation complications like renal failure and PV rethrombosis, and operative difficulty and patient survival are similar to those in recipients without PVT. Development of therapeutic approaches and accumulation of experience in dealing with PVT further improve the outcomes of LT in PVT recipients.

Tailored classification of portal vein thrombosis for liver transplantation:Focus on strategies for portal vein inflow reconstruction

Portal vein thrombosis(PVT)is currently not considered a contraindication for liver transplantation(LT),but diffuse or complicated PVT remains a major surgical challenge.Here,we review the prevalence,natural course and current grading systems of PVT and propose a tailored classification of PVT in the setting of LT.PVT in liver transplant recipients is classified into three types,corresponding to three portal reconstruction strategies:Anatomical,physiological and non-physiological.Type I PVT can be removed via low dissection of the portal vein(PV)or thrombectomy;porto-portal anastomosis is then performed with or without an interposed vascular graft.Physiological reconstruction used for type II PVT includes vascular interposition between mesenteric veins and PV,collateral-PV and splenic vein-PV anastomosis.Non-physiological reconstruction used for type III PVT includes cavoportal hemitransposition,renoportal anastomosis,portal vein arterialization and multivisceral transplantation.All portal reconstruction techniques were reviewed.This tailored classification system stratifies PVT patients by surgical complexity,risk of postoperative complications and long-term survival.We advocate using the tailored classification for PVT grading before LT,which will urge transplant surgeons to make a better preoperative planning and pay more attention to all potential strategies for portal reconstruction.Further verification in a large-sample cohort study is needed.