Reply
Authors: Joseph Ralph Kallini, Ahmed Gabr, Laura Kulik, Daniel Ganger, Robert Lewandowski, Bartley Thornburg, Riad Salem
Journal: Hepatology (2016)

Potential conflict of interest: Nothing to report. Reply: We thank Wang et al. for their comments regarding the use of trans‐splenic portal vein recanalization transjugular intrahepatic portosystemic shunt (PVR‐TIPS) in patients without cirrhosis who have complete obliterative portal venous thrombosis (PVT). First, although it is true that the gastrointestinal (GI) bleeding rate in patients who have PVT but not cirrhosis is lower than that in patients who have cirrhosis, outcomes are worse in those without cirrhosis.1 As a result, the American Association for the Study of Liver Diseases (AASLD) currently suggests screening patients who do not have cirrhosis for esophageal varices, starting bleeding prophylaxis if varices are present, considering chronic anticoagulation, and managing complications symptomatically. Beta‐blockers and band ligation are both recommended for variceal bleeding prophylaxis, but this recommendation is only supported by class IIa, level C evidence2; thus, clinical judgment remains an integral component of treatment. The authors cite a trial that showed equal efficacy of beta‐blockers and variceal ligation, but this study did not include a control group and did not compare medical therapy with TIPS. It is not likely to raise the current level of evidence.3 In our experience, PVR‐TIPS has prevented recurrent life‐threatening hemorrhage and should be considered an option for complete obliterative PVT in patients who do not have cirrhosis. Second, the AASLD guidelines emphasize prevention of GI bleeding as a goal not only of managing PVT in the absence of cirrhosis but also of preventing recurrent thrombosis and treatment of portal cholangiopathy (from enlarged portal/antral/duodenal/biliary veins compressing the biliary tree).4 The mortality associated with thrombotic events in chronic PVT (independent of liver function) is higher than that of GI bleeding (as shown by a similar death rate despite 67% incidence of thrombotic events compared with GI bleeding).1 Moreover, chronic PVT in the absence of cirrhosis results in a nontrivial percentage of subclinical encephalopathy (50%) and hepatopulmonary syndrome (10%).4 PVR‐TIPS addresses all of these instances by dealing with the underlying PVT. Two of our 5 patients had extensive portal, superior mesenteric, and splenic vein thrombosis, and this resulted in splenic infarct in one patient. Indeed, one of the main complications of PVT is intestinal ischemia.1 PVR‐TIPS addressed the thrombosis and flow gradient with no thrombosis‐associated sequelae to date. Controlled studies in patients with cirrhosis show that TIPS results in nearly 100% recanalization in recent or chronic PVT.5 We feel that these results apply to PVT regardless of liver function. Finally, we agree with the theoretical risk that splenic stenting may hinder mesenteric venous flow. However, that patient exhibited a completely occluded mesenteric venous system draining exclusively through collateral vessels. PVR‐TIPS was performed for massive variceal bleeding requiring anticoagulation discontinuation. Splenic stenting, which is rarely practiced in our group, was beneficial in this case for inline flow. We agree that chronic PVT should be managed conservatively. However, we feel that radical management is required for patients without cirrhosis who have longstanding PVT, even in the nonemergent setting. PVR‐TIPS is an effective tool for such select cases.