Tips for portal vein thrombosis (pvt) in cirrhosis: Not only unblocking a pipe
Authors: Marco Senzolo, Patrizia Burra, D. Patch, Andrew K. Burroughs
Journal: Journal of Hepatology (2011)

Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosisJournal of HepatologyVol. 54Issue 1PreviewData on the management of portal vein thrombosis (PVT) in patients with decompensated cirrhosis are extremely limited, particularly in the cases of the transjugular intrahepatic portosystemic shunt (TIPS). We assessed the outcome of TIPS for PVT in patients with cirrhosis and symptomatic portal hypertension and determined the predictors of technical success and survival. Full-Text PDF Reply to:Tips for portal vein thrombosis (pvt) in cirrhosis: Not only unblocking a pipeJournal of HepatologyVol. 55Issue 4PreviewTIPS for portal vein thrombosis (PVT): Still a long way to go Full-Text PDF Open Access Han et al. recently published a case series of patients with cirrhosis who had developed portal and splanchnic vein thrombosis at various intervals from treatment with transjugular intrahepatic portosystemic shunt (TIPS), for complications of the resulting portal hypertension [[1]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: 78-88Abstract Full Text Full Text PDF PubMed Scopus (176) Google Scholar]. We are pleased that they confirmed our published findings that TIPS is feasible and effective in patients with PVT, including those with cavernous transformation of the portal vein [[2]Senzolo M. Tibbals J. Cholongitas E. Triantos C.K. Burroughs A.K. Patch D. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation.Aliment Pharmacol Ther. 2006; 23: 767-775Crossref PubMed Scopus (169) Google Scholar].They also reported predictive factors related to the technical feasibility of TIPS, suggesting that only in patients with complete occlusion of the main portal vein and fine collaterals at the hepatic hilum, was TIPS not worthwhile, because of a high risk of failure. Although the present study has the largest series of patients with cirrhosis and PVT assessed for TIPS, we feel there are some important issues that deserve comment, to maintain a balanced and objective view.First, although patients were classified according to a definition of acute or chronic thrombosis (which included the presence of an established cavernoma in 30 of 57 patients), an estimation of the age of the thrombus before TIPS was not reported, and moreover, in the table, all patients were defined as chronic, despite the authors statement that a cavernoma was not considered as a clear sign of long standing thrombosis.Second, 70% of patients had an extension of thrombosis into the splanchnic vessels: 79% having splenic vein thrombosis (SVT) and 75% mesenteric vein thrombosis (SMVT) and 53% cavernomas. Somewhat surprisingly, the authors managed to completely repermeate all the thrombosed vessels in all patients in whom TIPS was placed. This is quite exceptional, in addition to the fact that this result was obtained solely by using angioplasty.Third, if a complete repermeation of the splanchnic vessels could not be accomplished by angioplasty, this was an indication to abandon the procedure, because of a presumed high risk of shunt failure if a TIPS was to be placed. A firm recommendation was given to place stents in the SMV if there was residual thrombus in the SMV.Our published and subsequent experience contradicts these aspects [[2]Senzolo M. Tibbals J. Cholongitas E. Triantos C.K. Burroughs A.K. Patch D. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation.Aliment Pharmacol Ther. 2006; 23: 767-775Crossref PubMed Scopus (169) Google Scholar]. A complete thrombosis of the main portal vein should not be considered a contraindication to TIPS providing the intrahepatic branches are visible, as a direct puncture can be performed by the tranjugular route. Indeed in our series, patency of intrahepatic portal branches was the only significant predictor of technical success of TIPS, even when there was cavernomatous transformation of the portal vein. Transhepatic puncture cannot be performed and is risky if the intrahepatic branches of the portal vein are thrombosed, and a transplenic approach is also risky and unlikely to succeed.We found that mechanical disruption of the thrombus is not always feasible (especially so with only angioplasty), particularly in patients with long standing thrombosis. However, when thrombectomy could not be accomplished in all thrombosed splanchnic vessels, restoring portal flow with placement of TIPS, together with anticoagulation, allowed repermeation of some vessels in the long term.When we evaluated together, both our published series of PVT in cirrhosis [[2]Senzolo M. Tibbals J. Cholongitas E. Triantos C.K. Burroughs A.K. Patch D. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation.Aliment Pharmacol Ther. 2006; 23: 767-775Crossref PubMed Scopus (169) Google Scholar], and patients enrolled in a prospective protocol of treatment of PVT [[3]Senzolo M. Sartori M.T. Rossetto Valeria Cillo Umberto Rodriguez Kryssia I. Nadal Elena et al.Hepatology. 2010; 52: 903AAbstract Full Text Full Text PDF Scopus (46) Google Scholar], we had 25 patients: 17 males, mean age 48 years (range 17–65), alcohol related cirrhosis in 11 patients, Child class A/B/C were 14/12/9. Fourteen patients had complete PVT with extension into SMV in 8, and SV alone in 5 cases, and 6 had cavernomas. The indication for attempt at TIPS placement was: emergency for variceal bleeding in 7, recurrent bleeding in 6, ascites in 4, and treatment of progressive PVT despite anticoagulation in 7. TIPS was successfully placed in 20/25 patients (80%). No transhepatic approach was attempted and we here confirmed that the absence of visible intrahepatic branches was the only factor significantly correlated with the risk of failure for TIPS placement: 5/5 failure group versus 1/20 success group (p<0.001).Another difference in our series is that despite thrombectomy only being feasible in 58%, the restored flow in the portal vein (although only partial in some cases) resulted in the absence of bleeding episodes during follow up, with a similar rate of stent dysfunction reported by Han et al. (22% and 33% at 1 and 2 year, respectively). Notably, in one patient of our series with long standing thrombosis in portal, superior mesenteric, and splenic veins, who had emergency TIPS for bleeding duodenal varices and developed TIPS occlusion, anticoagulation resulted in complete repermeation of all the splanchnic vessels, even though the TIPS remained thrombosed.It is important to note that we never extended the TIPS stent into the SMV. As PVT occurs more frequently in patients with advanced liver disease who are more likely to be candidates for liver transplantation, the extension of the stent distally into the extrahepatic main trunk of the portal vein or into the SMV can jeopardize the transplant surgery [[4]Senzolo M. Riggio O. Primignani M. Vascular disorders of the liver: Recommendations from the Italian association for the study of the liver (AISF) ad hoc committee.Dig Liver Dis. 2011; 43: 503-514Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar].Both our series and the one from China clearly establish that TIPS is feasible in extensive splanchnic thrombosis to treat portal hypertensive complications. However, we believe the role of TIPS needs redefining: it should be considered in all patients with cirrhosis and PVT, who are candidates for liver transplantation, whenever anticoagulation is contraindicated, or if there is progression of thrombosis despite anticoagulation – this will result in repermeation and patency of the portal vein, in a large proportion of patients [[5]Tsochatzis E.A. Senzolo M. Germani G. Gatt A. Burroughs A.K. Systematic review: portal vein thrombosis in cirrhosis.Aliment Pharmacol Ther. 2010; 31: 366-374Crossref PubMed Scopus (217) Google Scholar]. This should facilitate surgery and decrease morbidity and mortality after transplantation.Conflict of interestThe authors declared that they do not have anything to disclose regarding funding or conflicts of interest with respect to this manuscript. Han et al. recently published a case series of patients with cirrhosis who had developed portal and splanchnic vein thrombosis at various intervals from treatment with transjugular intrahepatic portosystemic shunt (TIPS), for complications of the resulting portal hypertension [[1]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: 78-88Abstract Full Text Full Text PDF PubMed Scopus (176) Google Scholar]. We are pleased that they confirmed our published findings that TIPS is feasible and effective in patients with PVT, including those with cavernous transformation of the portal vein [[2]Senzolo M. Tibbals J. Cholongitas E. Triantos C.K. Burroughs A.K. Patch D. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation.Aliment Pharmacol Ther. 2006; 23: 767-775Crossref PubMed Scopus (169) Google Scholar]. They also reported predictive factors related to the technical feasibility of TIPS, suggesting that only in patients with complete occlusion of the main portal vein and fine collaterals at the hepatic hilum, was TIPS not worthwhile, because of a high risk of failure. Although the present study has the largest series of patients with cirrhosis and PVT assessed for TIPS, we feel there are some important issues that deserve comment, to maintain a balanced and objective view. First, although patients were classified according to a definition of acute or chronic thrombosis (which included the presence of an established cavernoma in 30 of 57 patients), an estimation of the age of the thrombus before TIPS was not reported, and moreover, in the table, all patients were defined as chronic, despite the authors statement that a cavernoma was not considered as a clear sign of long standing thrombosis. Second, 70% of patients had an extension of thrombosis into the splanchnic vessels: 79% having splenic vein thrombosis (SVT) and 75% mesenteric vein thrombosis (SMVT) and 53% cavernomas. Somewhat surprisingly, the authors managed to completely repermeate all the thrombosed vessels in all patients in whom TIPS was placed. This is quite exceptional, in addition to the fact that this result was obtained solely by using angioplasty. Third, if a complete repermeation of the splanchnic vessels could not be accomplished by angioplasty, this was an indication to abandon the procedure, because of a presumed high risk of shunt failure if a TIPS was to be placed. A firm recommendation was given to place stents in the SMV if there was residual thrombus in the SMV. Our published and subsequent experience contradicts these aspects [[2]Senzolo M. Tibbals J. Cholongitas E. Triantos C.K. Burroughs A.K. Patch D. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation.Aliment Pharmacol Ther. 2006; 23: 767-775Crossref PubMed Scopus (169) Google Scholar]. A complete thrombosis of the main portal vein should not be considered a contraindication to TIPS providing the intrahepatic branches are visible, as a direct puncture can be performed by the tranjugular route. Indeed in our series, patency of intrahepatic portal branches was the only significant predictor of technical success of TIPS, even when there was cavernomatous transformation of the portal vein. Transhepatic puncture cannot be performed and is risky if the intrahepatic branches of the portal vein are thrombosed, and a transplenic approach is also risky and unlikely to succeed. We found that mechanical disruption of the thrombus is not always feasible (especially so with only angioplasty), particularly in patients with long standing thrombosis. However, when thrombectomy could not be accomplished in all thrombosed splanchnic vessels, restoring portal flow with placement of TIPS, together with anticoagulation, allowed repermeation of some vessels in the long term. When we evaluated together, both our published series of PVT in cirrhosis [[2]Senzolo M. Tibbals J. Cholongitas E. Triantos C.K. Burroughs A.K. Patch D. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation.Aliment Pharmacol Ther. 2006; 23: 767-775Crossref PubMed Scopus (169) Google Scholar], and patients enrolled in a prospective protocol of treatment of PVT [[3]Senzolo M. Sartori M.T. Rossetto Valeria Cillo Umberto Rodriguez Kryssia I. Nadal Elena et al.Hepatology. 2010; 52: 903AAbstract Full Text Full Text PDF Scopus (46) Google Scholar], we had 25 patients: 17 males, mean age 48 years (range 17–65), alcohol related cirrhosis in 11 patients, Child class A/B/C were 14/12/9. Fourteen patients had complete PVT with extension into SMV in 8, and SV alone in 5 cases, and 6 had cavernomas. The indication for attempt at TIPS placement was: emergency for variceal bleeding in 7, recurrent bleeding in 6, ascites in 4, and treatment of progressive PVT despite anticoagulation in 7. TIPS was successfully placed in 20/25 patients (80%). No transhepatic approach was attempted and we here confirmed that the absence of visible intrahepatic branches was the only factor significantly correlated with the risk of failure for TIPS placement: 5/5 failure group versus 1/20 success group (p<0.001). Another difference in our series is that despite thrombectomy only being feasible in 58%, the restored flow in the portal vein (although only partial in some cases) resulted in the absence of bleeding episodes during follow up, with a similar rate of stent dysfunction reported by Han et al. (22% and 33% at 1 and 2 year, respectively). Notably, in one patient of our series with long standing thrombosis in portal, superior mesenteric, and splenic veins, who had emergency TIPS for bleeding duodenal varices and developed TIPS occlusion, anticoagulation resulted in complete repermeation of all the splanchnic vessels, even though the TIPS remained thrombosed. It is important to note that we never extended the TIPS stent into the SMV. As PVT occurs more frequently in patients with advanced liver disease who are more likely to be candidates for liver transplantation, the extension of the stent distally into the extrahepatic main trunk of the portal vein or into the SMV can jeopardize the transplant surgery [[4]Senzolo M. Riggio O. Primignani M. Vascular disorders of the liver: Recommendations from the Italian association for the study of the liver (AISF) ad hoc committee.Dig Liver Dis. 2011; 43: 503-514Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar]. Both our series and the one from China clearly establish that TIPS is feasible in extensive splanchnic thrombosis to treat portal hypertensive complications. However, we believe the role of TIPS needs redefining: it should be considered in all patients with cirrhosis and PVT, who are candidates for liver transplantation, whenever anticoagulation is contraindicated, or if there is progression of thrombosis despite anticoagulation – this will result in repermeation and patency of the portal vein, in a large proportion of patients [[5]Tsochatzis E.A. Senzolo M. Germani G. Gatt A. Burroughs A.K. Systematic review: portal vein thrombosis in cirrhosis.Aliment Pharmacol Ther. 2010; 31: 366-374Crossref PubMed Scopus (217) Google Scholar]. This should facilitate surgery and decrease morbidity and mortality after transplantation. Conflict of interestThe authors declared that they do not have anything to disclose regarding funding or conflicts of interest with respect to this manuscript. The authors declared that they do not have anything to disclose regarding funding or conflicts of interest with respect to this manuscript.