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.

Transileocolic endovascular treatment by a hybrid approach for severe acute portal vein thrombosis with bowel necrosis:Two case reports

BACKGROUND Acute portal vein thrombosis(PVT)with bowel necrosis is a fatal condition with a 50%-75%mortality rate.This report describes the successful endovascular treatment(EVT)of two patients with severe PVT.CASE SUMMARY The first patient was a 22-year-old man who presented with abdominal pain lasting 3 d.The second patient was a 48-year-old man who presented with acute abdominal pain.Following contrast-enhanced computed tomography,both patients were diagnosed with massive PVT extending to the splenic and superior mesenteric veins.Hybrid treatment(simultaneous necrotic bowel resection and EVT)was performed in a hybrid operating room(OR).EVTs,including aspiration thrombectomy,catheter-directed thrombolysis(CDT),and continuous CDT,were performed via the ileocolic vein under laparotomy.The portal veins were patent 4 and 6 mo posttreatment in the 22-year-old and 48-year-old patients,respectively.CONCLUSION Hybrid necrotic bowel resection and transileocolic EVT performed in a hybrid OR is effective and safe.

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.

Liver transplantation and resection in patients with hepatocellular cancer and portal vein tumor thrombosis: Feasible and effective?

Patients with locally advanced hepatocellular cancer(HCC)and portal vein tumor thrombosis(PVTT)have a dismal prognosis since limited treatment options are available for them.In recent years,effective systemic therapy,and advances in the understanding of technicalities and effectiveness of ablative therapies especially radiotherapy,have given some hope to prolong survival in them.This review summarized recent evidence in literature regarding the possible role of liver resection(LR)and liver transplantation(LT)in patients with locally advanced HCC and PVTT with no extrahepatic disease.Downstaging therapies have helped make curative resection or LT a reality in selected patients.This review emphasizes on the key points to focus on when considering surgery in these patients,who are usually relegated to palliative systemic therapy alone.Meticulous patient selection based on tumor biology,documented downstaging based on imaging and decrease in tumor marker levels,and an adequate waiting period to demonstrate stable disease,may help obtain satisfactory long-term outcomes post LR or LT in an intention to treat strategy in patients with HCC and PVTT.

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.

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.

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.

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.

Hepatocellular carcinoma associated with tumor thrombosis in the portal vein: the effects of different treatments

OBJECTIVES: To compare the effects of different treatments for hepatocellular carcinoma (HCC) with tumor thrombosis in the portal vein (TTPV) and evaluate the factors influencing the prognosis. METHODS: One hundred and thirty-eight patients with HCC associated with TTPV, whose liver function was compensative and the tumor with TTPV can probably be resected together, were divided into four groups: conservative treatment group (n=14); chemotherapy group (n=19); surgical resection group (n=19); and surgical resection with postoperative chemotherapy group (n=64). RESULTS: The median survivals of the four groups were 3.5, 7.1, 10.1 and 13.4 months, respectively. The 0.5-, 1-, 2-, and 3-year cumulative survival rates of the surgical resection with postoperative chemotherapy group were 53.7%, 37.6%, 30.7% and 14.0% respectively, which were significantly higher than those of the other three groups (P<0.05). Both univariate and multivariate analysis revealed that postoperative chemotherapeutic course was the most important factor affecting the surgical results. CONCLUSIONS: If patients' liver fimction is compensative and tumors with TTPV can be removed together, exploration should be done. Surgical resection combined with postoperative chemotherapy can achieve the best results. More chemotherapeutic courses after surgical resection can be prescribed if the patients have good hepatic functional reserve.

Application of transmesenteric vein extrahepatic portosystemic shunt in treatment of symptomatic portal hypertension with cavernous transformation of portal vein

Purpose:To evaluate the feasibility and efficacy of a transmesenteric vein extrahepatic portosystemic shunt(TmEPS)for the treatment of cavernous transformation of the portal vein(CTPV).Materials and methods:The clinical data of 20 patients with CTPV who underwent TmEPS between December 2020and January 2022 at Henan Provincial People’s Hospital were retrospectively collected.The superior mesenteric vein(SMV)trunk was patent or partially occluded in these patients.An extrahepatic portosystemic shunt between the inferior vena cava and the SMV was established using a stent graft through an infraumbilical median longitudinal mini-laparotomy.The technical success,efficacy,and complication rates were evaluated,and the preand postoperative SMV pressures were compared.Patients’clinical outcomes and shunt patency were assessed.Results:TmEPS was successfully performed in 20 patients.The initial puncture success rate of the balloon-assisted puncture technique is 95%.The mean SMV pressure decreased from 29.1±2.9 mmHg to 15.6±3.3 mmHg(p<0.001).All symptoms of portal hypertension resolved.No fatal procedural complications occurred.During the follow-up period,hepatic encephalopathy occurred in two patients.The remaining patients remained asymptomatic.All shunts were patent.Conclusions:TmEPS is a feasible,safe,and effective treatment option for patients with CTPV.

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.

Agitation thrombolysis combined with catheter-directed thrombolysis for the treatment of non-cirrhotic acute portal vein thrombosis

AIM To evaluate the safety and efficacy of agitation thrombolysis(AT) combined with catheter-directed thrombolysis(CDT) for the treatment of non-cirrhotic acute portal vein thrombosis(PVT). METHODS Nine patients with non-cirrhotic acute PVT who underwent AT combined with CDT were analyzed retrospectively. Portography was carried out via the transjugular intrahepatic portosystemic(commonly known as TIP) or percutaneous transhepatic(commonly known as PT) route, followed by AT combined with CDT. Complications of the procedure, and the changes in clinical symptoms, hemodynamics of the portal vein and liver function were recorded. Follow-up was scheduled at1, 3 and 6 mo after treatment, and every 6 mo thereafter, or when the patients developed clinical symptoms related to PVT. Color Doppler ultrasound and contrast-enhanced computed tomography/magnetic resonance imaging were performed during the follow-up period to determine the condition of the portal vein.RESULTS AT combined with CDT was successfully performed. The portal vein was reached via the TIP route in 6 patients, and via the PT route in 3 patients. All clinical symptoms were relieved or disappeared, with the exception of 1 patient who died of intestinal necrosis 9 d after treatment. Significant differences in the changes in portal vein hemodynamics were observed, including the maximum lumen occupancy of PVT, portal vein pressure and flow velocity between pre-and posttreatment(P < 0.05). During the follow-up period, recurrence was observed in 1 patient at 19 mo after the procedure, and the portal vein was patent in the remaining patients.CONCLUSION AT combined with CDT is a safe and effective method for the treatment of non-cirrhotic acute PVT.

Efficacy of different treatment strategies for hepatocellular carcinoma with portal vein tumor thrombosis

AIM: To evaluate the efficacy of different treatment strategies for hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) and investigate factors influencing prognosis.METHODS: One hundred and seventy-nine HCC patients with macroscopic PVTT were enrolled in this study. They were divided into four groups and underwent different treatments: conservative treatment group (n = 18),chemotherapy group (n = 53), surgical resection group (n = 24) and surgical resection with postoperative chemotherapy group (n = 84). Survival rates of the patients were analyzed by the Kaplan-Meier method. A log-rank analysis was performed to identify group differences. Cox's proportional hazards model was used to analyze variables associated with survival.RESULTS: The mean survival periods of the patients in four groups were 3.6, 7.3, 10.1, and 15.1 mo respectively.There were significant differences in the survival rates among the groups. The survival rates at 0.5-, 1-, 2-, and 3-year in surgical resection with postoperative chemotherapy group were 55.8%, 39.3%, 30.4%, and 15.6% respectively, which were significantly higher than those of other groups (P＜0.001). Multivariate analysis revealed that the strategy of treatment (P＜0.001) and the number of chemotherapy cycles (P = 0.012) were independent survival predictors for patients with HCC and PVTT.CONCLUSION: Surgical resection of HCC and PVTT combined with postoperative chemotherapy or chemoembolization is the most effective therapeutic strategy for the patients who can tolerate operation.Multiple chemotherapeutic courses should be given postoperatively to the patients with good hepatic function reserve.

Percutaneous electrochemotherapy in the treatment of portal vein tumor thrombosis at hepatic hilum in patients with hepatocellular carcinoma in cirrhosis: A feasibility study

AIM To treated with electrochemotherapy(ECT) a prospective case series of patients with liver cirrhosis and Vp3-Vp4- portal vein tumor thrombus(PVTT) from hepatocellular carcinoma(HCC), in order to evaluate the feasibility, safety and efficacy of this new non thermal ablative technique in those patients. METHODS Six patients(5 males and 1 female), aged 61-85 years(mean age, 70 years), four in Child-Pugh A and two in Child-Pugh B class, entered our study series. All patients were studied with three-phase computed tomography(CT), contrast enhanced ultrasound(CEUS) and ultrasound-guided percutaneous biopsy of the thrombus before ECT. All patients underwent ECT treatment(Cliniporator Vitae?, IGEA Sp A, Carpi, Modena, Italy) of Vp3-Vp4 PVTT in a single session. At the end of the procedure a post-treatment biopsy of the thrombus was performed. Scheduled follow-up in all patients entailed: CEUS within 24 h after treatment; triphasic contrastenhanced CT and CEUS at 3 mo after treatment and every six months thereafter.RESULTS Post-treatment CEUS showed complete absence of enhancement of the treated thrombus in all cases. Post-treatment biopsy showed apoptosis and necrosis of tumor cells in all cases. The follow-up ranged from 9 to 20 mo(median, 14 mo). In 2 patients, the followup CT and CEUS demonstrated complete patency of the treated portal vein. Other 3 patients showed a persistent avascular non-tumoral shrinked thrombus at CEUS and CT during follow-up. No local recurrence was observed at follow-up CT and CEUS in 5/6 patients. One patient was lost to follow-up because of death from gastrointestinal hemorrage 5 wk after ECT. CONCLUSION In patients with cirrhosis, ECT seems effective and safe for curative treatment of Vp3-Vp4 PVTT from HCC.

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.

Reconstructing the portal vein through a posterior pancreatic tunnel:New choice for portal vein thrombosis during liver transplantation

BACKGROUND Thrombectomy and anatomical anastomosis(TAA)has long been considered the optimal approach to portal vein thrombosis(PVT)in liver transplantation(LT).However,TAA and the current approach for non-physiological portal reconstructions are associated with a higher rate of complications and mortality in some cases.AIM To describe a new choice for reconstructing the portal vein through a posterior pancreatic tunnel(RPVPPT)to address cases of unresectable PVT.METHODS Between August 2019 and August 2021,245 adult LTs were performed.Forty-five(18.4%)patients were confirmed to have PVT before surgery,among which seven underwent PV reconstruction via the RPVPPT approach.We retrospectively analyzed the surgical procedure and postoperative complications of these seven recipients that underwent PV reconstruction due to PVT.RESULTS During the procedure,PVT was found in all the seven cases with significant adhesion to the vascular wall and could not be dissected.The portal vein proximal to the superior mesenteric vein was damaged in one case when attempting thrombolectomy,resulting in massive bleeding.LT was successfully performed in all patients with a mean duration of 585 min(range 491-756 min)and mean intraoperative blood loss of 800 mL(range 500-3000 mL).Postoperative complications consisted of chylous leakage(n=3),insufficient portal venous flow to the graft(n=1),intra-abdominal hemorrhage(n=1),pulmonary infection(n=1),and perioperative death(n=1).The remaining six patients survived at 12-17 mo follow-up.CONCLUSION The RPVPPT technique might be a safe and effective surgical procedure during LT for complex PVT.However,follow-up studies with large samples are still warranted due to the relatively small number of cases.

Treatment of hepatocellular carcinoma in patients with portal vein tumor thrombosis: Beyond the known frontiers

Hepatocellular carcinoma is one of the most frequent malignant tumors worldwide:Portal vein tumor thrombosis(PVTT)occurs in about 35%-50%of patients and represents a strong negative prognostic factor,due to the increased risk of tumor spread into the bloodstream,leading to a high recurrence risk.For this reason,it is a contraindication to liver transplantation and in several prognostic scores sorafenib represents its standard of care,due to its antiangiogenetic action,although it can grant only a poor prolongation of life expectancy.Recent scientific evidences lead to consider PVTT as a complex anatomical and clinical condition,including a wide range of patients with different prognosis and new treatment possibilities according to the degree of portal system involvement,tumor biological aggressiveness,complications caused by portal hypertension,patient’s clinical features and tolerance to antineoplastic treatments.The median survival has been reported to range between 2.7 and 4 mo in absence of therapy,but it can vary from 5 mo to 5 years,thus depicting an extremely variable scenario.For this reason,it is extremely important to focus on the most adequate strategy to be applied to each group of PVTT patients.

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.

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 of poor prognosis and portal vein tumor thrombosis after curative resection of solitary hepatocellular carcinoma

BACKGROUND:Predictors of poor prognosis of solitary hepatocellular carcinoma(SHCC),a subgroup encompassing most patients with the malignancy,are still controversial.Hence,risk factors for portal vein tumor thrombosis(PVTT) in SHCC are obscure.The present study was designed to address this issue.METHOD:Clinicopathological and follow-up data for 156 consecutive patients with SHCC following curative hepatic resection were analyzed using uni-and multi-variate analyses.RESULTS:Univariate analysis showed that PVTT,tumornode-metastasis(TNM) stage,Edmondson-Steiner grade and preoperative serum alpha-fetoprotein(AFP) level were associated with the overall and disease-free survival,whereas tumor size only influenced the overall survival.In multivariate Cox regression tests,Edmondson-Steiner grade and TNM stage were independent prognostic markers for both overall and diseasefree survival.In addition,the Chi-square test showed that AFP level and Edmondson-Steiner grade were correlated with PVTT.Among them,only Edmondson-Steiner grade was shown to be of independent significance for PVTT in multi-variate logistic regression analysis.Additionally,AFP,the sole preoperative factor for PVTT,was not adequately sensitive and specific.CONCLUSIONS:Factors relating to post-surgical prognosis and PVTT in SHCC are all tumor-related.Of these,EdmondsonSteiner grade and TNM stage might be of particular importance in survival analysis.In addition,accurate prediction of PVTT by clinicopathological parameters before surgery remains difficult.