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Gastroenterology Aug 2017Liver cirrhosis is complicated by bleeding from portal hypertension but also by portal vein thrombosis (PVT). PVT occurs in approximately 20% to 50% of patients with... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND & AIMS
Liver cirrhosis is complicated by bleeding from portal hypertension but also by portal vein thrombosis (PVT). PVT occurs in approximately 20% to 50% of patients with cirrhosis, and is a warning sign for poor outcome. It is a challenge to treat patients with cirrhosis using anticoagulants, because of the perception that the coexistent coagulopathy could promote bleeding. We performed a systematic review and meta-analysis to determine the effects of anticoagulant therapy in patients with cirrhosis and PVT.
METHODS
We searched the PubMed, ISI Web of Science, SCOPUS, and Cochrane databases through February 14, 2017, for studies that assessed the effect of anticoagulant therapy vs no treatment in patients with cirrhosis and PVT. We performed a meta-analysis to estimate the effect of anticoagulant treatment vs no therapy on recanalization and progression of PVT in patients with cirrhosis. We also assessed variceal and nonvariceal bleeding.
RESULTS
We analyzed data from 8 studies, comprising 353 patients, that assessed the effects of anticoagulant therapy (low-weight heparin or warfarin vs no therapy) in patients with cirrhosis and PVT; these studies reported rates of complete and partial recanalization. A significantly higher proportion of patients treated with anticoagulants underwent PVT recanalization than patients who did not receive anticoagulants (71% vs 42%, respectively; P < .0001). From 6 studies (comprising 217 patients), 53% of patients treated with anticoagulants vs 33% of patients who did not receive anticoagulants had complete PVT recanalization (P = .002). From 6 studies (comprising 225 patients), PVT progressed in 9% of patients treated with anticoagulants vs 33% of patients who did not receive these drugs (P < .0001). Six studies (257 patients) reported rates of any bleeding; there was no difference in the proportions of patients with major or minor bleeding between groups that did vs did not receive anticoagulants (11% for both groups). Four studies (comprising 158 patients) reported rates of spontaneous variceal bleeding, which occurred in a significantly lower proportion of patients who received anticoagulants vs those who did not (P = .04).
CONCLUSIONS
Based on a systematic review and meta-analysis, patients with cirrhosis and PVT who receive anticoagulant therapy have increased recanalization and reduced progression of thrombosis, compared with patients who do not receive anticoagulants, with no excess of major and minor bleedings and less incidence of variceal bleeding.
Topics: Anticoagulants; Disease Progression; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Incidence; Liver Cirrhosis; Male; Middle Aged; Portal Vein; Treatment Outcome; Venous Thrombosis
PubMed: 28479379
DOI: 10.1053/j.gastro.2017.04.042 -
Vascular and Endovascular Surgery Jul 2021To evaluate the efficacy of Angioplasty and Stent Placement for the treatment of Portal Vein Stenosis in Liver Transplant Recipients by performing a systematic review.
PURPOSE
To evaluate the efficacy of Angioplasty and Stent Placement for the treatment of Portal Vein Stenosis in Liver Transplant Recipients by performing a systematic review.
MATERIALS AND METHODS
The PubMed Database was extensively searched for articles describing Portal Vein Stenosis (PVS) as a complication in Liver Transplant (LT) patients. The initial database search yielded 488 unique records published in the PubMed Database, 19 of which were deemed to meet the inclusion criteria. Outcomes were separated into 2 groups (Group A included patients with primary angioplasty, Group B included patients with primary stent placement), and further subdivided into Adult and Pediatric populations.
RESULTS
Group A included a total of 282 LT patients with portal vein stenosis. The population was predominantly pediatric (n = 243). Group B included a total of 111 LT patients with portal vein stenosis. This population was predominantly adult (n = 66). Technical success was significantly higher in both Group B pediatric (100%) and adults (97%) compared to Group A (69.5%) and (66.7%) respectively. Re-stenosis rates were significantly lower in Group B pediatric group compared to Group A (2.3% vs 29.7%, χ = 13.9; p < 0.001). Overall major (3.1%) and minor complications rates (1.5%) were low.
CONCLUSION
Primary stent placement appears to have higher technical success in both populations and lower re-stenosis rates for treatment of PVS in pediatric populations.
Topics: Adult; Aged; Angioplasty; Child; Child, Preschool; Constriction, Pathologic; Female; Humans; Infant; Infant, Newborn; Liver Transplantation; Male; Middle Aged; Portal Vein; Recurrence; Stents; Time Factors; Treatment Outcome; Vascular Diseases; Vascular Patency
PubMed: 33618615
DOI: 10.1177/1538574421994417 -
Transplantation Reviews (Orlando, Fla.) Dec 2021Portal vein obstruction (PVO) is a significant vascular complication after liver transplantation (LT) in pediatric patients. Current treatment strategies include... (Review)
Review
INTRODUCTION
Portal vein obstruction (PVO) is a significant vascular complication after liver transplantation (LT) in pediatric patients. Current treatment strategies include percutaneous transluminal angioplasty (PTA), with or without stent placement, mesorex bypass (MRB), splenorenal shunt, mesocaval shunt, endovascular recanalization (EVR), splenic artery embolization and splenectomy. However, specific characteristics of patients undergoing intervention and selection of individual treatment and its efficacy have remained unclear. This review systematically analyzed biochemical and clinical characteristics, selection of treatment, efficacy, and post-procedural complications.
METHODS
We systematically searched PubMed and Embase between January 1995 and March 2021 for studies on the management of PVO after LT. We analyzed the reports for biochemical and clinical characteristics at the timing of the intervention in different patients, selection of treatment, and reported efficacies.
RESULTS
We found 22 cohort studies with 362 patients who had the following characteristics: biliary atresia (83%), living-donor LT (85%), thrombocytopenia (73%), splenomegaly (40%), ascites (16%), or gastrointestinal bleeding (26%). The 3-year primary patency of PTA without stent placement was similar to that with stent placement (70%-80% and 43%-94%, respectively). MRB was used as an initial treatment with a 3-year patency of 75% to 100%. One study showed that 5-year primary patency of EVR was 80%. Secondary patency was 90% to 100% after 3 years in all studies with PTA alone, PTA/stent placement, and stent placement alone.
CONCLUSION
This is the first review of all treatment protocols in PVO after pediatric LT. We showed that an important group of patients has severe symptoms of portal hypertension. Efficacy of all treatment modalities was high in the included studies which make them important modalities for these patients.
Topics: Angioplasty; Child; Humans; Liver Transplantation; Portal Vein; Stents; Vascular Patency
PubMed: 34107368
DOI: 10.1016/j.trre.2021.100630 -
Frontiers in Pharmacology 2022Transjugular intrahepatic portosystemic shunt (TIPS) has been performed on patients with cirrhosis and portal vein thrombosis (PVT) to prevent rebleeding; however, the...
Transjugular intrahepatic portosystemic shunt (TIPS) has been performed on patients with cirrhosis and portal vein thrombosis (PVT) to prevent rebleeding; however, the associated evidence is scarce. Hence, the study aimed to evaluate the feasibility and efficacy of TIPS in patients with cirrhosis and PVT and promote personalized treatment in such patients. Literature was systematically obtained from PubMed, EMBASE, Cochrane Library, and Web of Science. Data from the included studies were extracted, and meta-analyses by the random effects model were used to pool data across studies. Heterogeneity was assessed using Cochran's Q and I statistics. The source of heterogeneity was explored using subgroup analyses and meta-regressions. A total of 11 studies comprising 703 patients with cirrhosis and portal vein thrombosis (PVT: complete, 32.2%; chronic, 90.2%; superior mesenteric vein or splenic vein involvement, 55.2%; cavernous transformation, 26.8%) were included. TIPS showed feasibility in 95% of the cases (95% confidence interval [CI]: 89%-99%) with heterogeneity (I = 84%, < 0.01) due to cavernous transformation. The pooled rebleeding rate was 13% (95% CI: 7%-20%) with heterogeneity (I = 75%, < 0.01) explained by chronic PVT and anticoagulation (AC) therapy. Hepatic encephalopathy occurred in 32% of patients. The survival rate, portal vein recanalization rate, and shunt patency rate were 80%, 82%, and 77%, respectively. TIPS is feasible and effectively prevents rebleeding in patients with cirrhosis and PVT, regardless of cavernous transformation of the portal vein. Due to a potentially high risk of rebleeding and no apparent benefits of AC, post-TIPS AC must be employed cautiously. : [https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=258765], identifier [CRD42021258765].
PubMed: 36052145
DOI: 10.3389/fphar.2022.968988 -
European Radiology Aug 2021It remains uncertain which embolization material is best for portal vein embolization (PVE). We investigated the various materials for effectiveness in inducing future... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
It remains uncertain which embolization material is best for portal vein embolization (PVE). We investigated the various materials for effectiveness in inducing future liver remnant (FLR) hypertrophy, technical and growth success rates, and complication and resection rates.
METHODS
A systematic review from 1998 to 2019 on embolization materials for PVE was performed on Pubmed, Embase, and Cochrane. FLR growth between the two most commonly used materials was compared in a random effects meta-analysis. In a separate analysis using local data (n = 52), n-butyl cyanoacrylate (NBCA) was compared with microparticles regarding costs, radiation dose, and procedure time.
RESULTS
In total, 2896 patients, 61.0 ± 4.0 years of age and 65% male, from 51 papers were included in the analysis. In 61% of the patients, either NBCA or microparticles were used for embolization. The remaining were treated with ethanol, gelfoam, or sclerosing agents. The FLR growth with NBCA was 49.1% ± 29.7 compared to 42.2% ± 40 with microparticles (p = 0.037). The growth success rate with NBCA vs microparticles was 95.3% vs 90.7% respectively (p < 0.001). There were no differences in major complications between NBCA and microparticles. In the local analysis, NBCA (n = 41) entailed shorter procedure time and reduced fluoroscopy time (p < 0.001), lower radiation exposure (p < 0.01), and lower material costs (p < 0.0001) than microparticles (n = 11).
CONCLUSION
PVE with NBCA seems to be the best choice when combining growth of the FLR, procedure time, radiation exposure, and costs.
KEY POINTS
• The meta-analysis shows that n-butyl cyanoacrylate (NBCA) is superior to microparticles regarding hypertrophy of the future liver remnant, 49.1% ± 29.7 vs 42.2% ± 40.0 (p = 0.037). • There is no significant difference in major complication rates for portal vein embolization using NBCA, 4% (24/681), compared with microparticles, 5% (25/494) (p > 0.05). • Local data shows a shorter procedure time, 215 vs 348 mins from arrival to departure at the interventional radiology unit, and fluoroscopy time, 43 vs 96 mins (p < 0.001), lower radiation dosage, 573 vs 1287 Gycm (p < 0.01), and costs, €816 vs €4233 (p < 0.0001) for NBCA compared to microparticles.
Topics: Aged; Embolization, Therapeutic; Enbucrilate; Female; Hepatectomy; Humans; Liver Neoplasms; Male; Portal Vein; Treatment Outcome
PubMed: 33501598
DOI: 10.1007/s00330-020-07685-w -
Cureus Aug 2021Thrombosis of the portal vein (PVT) is generally seen in the setting of liver cirrhosis and to a lesser extent in the absence of cirrhosis. There is no clear guidance in... (Review)
Review
Thrombosis of the portal vein (PVT) is generally seen in the setting of liver cirrhosis and to a lesser extent in the absence of cirrhosis. There is no clear guidance in relation to approaching treatment with anticoagulation in this condition. The professional societies and guidelines recommend treatment with traditional anticoagulation like low-molecular-weight heparin and vitamin-K antagonists in patients presenting with acute portal vein thrombosis. There is no clarity in relation to treatment in the setting of chronic PVT and in patients with cirrhosis. Also, the role of direct-acting oral anticoagulants (DOACs) that are becoming a preferred choice for anticoagulation for various other indications is not clear in the case of PVT. There are a very few studies in the medical literature that have investigated the role of DOACs in patients with PVT in different settings. Thus, we performed a systematic review of the literature to study the use of DOACs in PVT in patients with and without cirrhosis. The results of the available studies show that DOACS appears to be a promising choice for the treatment of patients with PVT. The availability of more data in the future along with better availability of the approved reversal agents for various DOACs is expected to make DOACS a preferred choice for the clinicians to treat patients with PVT.
PubMed: 34367844
DOI: 10.7759/cureus.16922 -
HPB : the Official Journal of the... Aug 2017Transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) with portal vein thrombosis (PVT) remains controversial. This systematic review sought to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) with portal vein thrombosis (PVT) remains controversial. This systematic review sought to examine the role of TACE in the treatment of HCC with PVT in either the main portal vein (MPV) or portal vein branches (PVB).
METHODS
PubMed was searched for "hepatocellular carcinoma" and "transarterial chemoembolization" from January 1, 2006 to August 31, 2016. Cohorts treated with TACE for HCC with PVT were included. Meta-analysis of overall survival (OS), mRECIST response, and complication incidence was performed. MPV and PVB subgroups were compared.
RESULTS
Of 136 search results, 13 studies with 1933 TACE patients were included. Median OS (95% CI) was eight (5-15) months. Survival rates after one, three, and five years were 29% (20%-40%), 4% (1%-11%), and 1% (0%-5%), respectively. Only 1% experienced liver failure and 18% had post-treatment complications. Patients with MPV thrombosis had worse survival than PVB patients (p < 0.001), but similar mRECIST response rates (14% vs. 16%, p = 0.238).
CONCLUSION
TACE is a safe treatment for a highly selected population of HCC patients with PVT. Despite worse survival rates compared to PVB thrombosis, PVT in the MPV should not be considered an absolute contraindication to TACE.
Topics: Carcinoma, Hepatocellular; Chemoembolization, Therapeutic; Humans; Liver Failure; Liver Neoplasms; Neoplastic Cells, Circulating; Portal Vein; Risk Factors; Survival Analysis; Time Factors; Treatment Outcome; Venous Thrombosis
PubMed: 28552299
DOI: 10.1016/j.hpb.2017.04.016 -
Clinical Transplantation Oct 2022A key tenet of clinical management of patients post liver transplantation (LT) is the prevention of thrombotic and bleeding complications. This systematic review...
What is the optimal management of thromboprophylaxis after liver transplantation regarding prevention of bleeding, hepatic artery, or portal vein thrombosis? A systematic review of the literature and expert panel recommendations.
BACKGROUND
A key tenet of clinical management of patients post liver transplantation (LT) is the prevention of thrombotic and bleeding complications. This systematic review investigated the optimal management of thromboprophylaxis after LT regarding portal vein thrombosis (PVT) or hepatic artery thrombosis (HAT) and prevention of bleeding.
METHODS
Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Seven databases were used to conduct extensive literature searches focusing on the use of anticoagulation in LT and its impact on the following outcomes: PVT, HAT, and bleeding (CRD42021244288).
RESULTS
Of the 2478 articles/abstracts screened, 16 studies were included in the final review. All articles were critically appraised by a panel of independent reviewers. There was wide variation regarding the anticoagulation protocols used. Thromboprophylaxis with therapeutic doses of heparin/Vitamin K antagonist combination did not decrease the risk of de novo or the recurrence of PVT but was associated with an increased risk of bleeding in some studies. Only the use of aspirin resulted in a small but significant decrease in the incidence of HAT post-LT, yet it did not increase the risk of bleeding.
CONCLUSIONS
Based on existing data and expert opinion, thromboprophylaxis at therapeutic or prophylactic dose is not recommended for prevention of de novo PVT following LT in patients not at high risk. Aspirin should be considered as the standard of care following LT to prevent HAT. Thromboprophylaxis should be strongly considered in recipients at risk of HAT and PVT following LT.
Topics: Humans; Liver Transplantation; Hepatic Artery; Portal Vein; Anticoagulants; Venous Thromboembolism; Venous Thrombosis; Liver Diseases; Thrombosis; Hemorrhage; Aspirin
PubMed: 35240723
DOI: 10.1111/ctr.14629 -
ANZ Journal of Surgery Dec 2020The aim of this study was to evaluate the safety and efficacy of low-molecular weight heparin (LMWH) in the prevention of portal vein system thrombosis (PVST) after... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The aim of this study was to evaluate the safety and efficacy of low-molecular weight heparin (LMWH) in the prevention of portal vein system thrombosis (PVST) after splenectomy.
METHODS
A systematic search was performed using PubMed, EMBASE, Springer and Cochrane Library databases to screen out studies comparing the prognoses between post-splenectomy patients treated with and without LMWH. The incidences of PVST and bleeding complications were used as parameters to assess the effect of LMWH.
RESULTS
Six articles met the selection criteria and were included in this study. A total of 740 patients were involved in these six articles, including 336 patients treated with LMWH (LMWH group) and 385 patients not treated with LMWH (control group). The incidence of PVST in the LMWH group was significantly lower than that in the control group (relative risk 1.782 (1.449-2.192); P = 0.285; I = 19.7%), while the incidence of post-operative bleeding in the LMWH group was significantly higher (relative risk 0.592 (0.195-1.799); P = 0.817; I = 0.0%).
CONCLUSION
LMWH might decrease the incidence of PVST after splenectomy without a potential risk of bleeding.
Topics: Anticoagulants; Heparin; Heparin, Low-Molecular-Weight; Humans; Molecular Weight; Portal Vein; Postoperative Complications; Splenectomy
PubMed: 32338419
DOI: 10.1111/ans.15865 -
European Journal of Radiology Nov 2023The morphometry of the hepatic portal vein is of clinical importance, particularly in pre-operative assessments, surgical management, and diagnoses of liver conditions.... (Meta-Analysis)
Meta-Analysis
PURPOSE
The morphometry of the hepatic portal vein is of clinical importance, particularly in pre-operative assessments, surgical management, and diagnoses of liver conditions. This systematic review and meta-analysis aimed to characterize the morphometry of the normal portal vein in both pediatric and adult patients.
METHODS
The study, conducted using the PRISMA guidelines and registered with PROSPERO, utilized the MEDLINE, EMBASE, SCOPUS and Web of Science databases up to May 2020, and updated to May 2023. All studies reporting extractable data on diameter, length, and cross-sectional area (CSA) of the main, left, and right portal veins (PV, LPV, RPV, respectively) were included. The AQUA Tool was used to assess the quality of the included studies. Data analysis included subgroup analyses based on geographical location, sex, age, and imaging modality.
RESULTS
A total of 122 studies with 11,637 subjects were eligible for inclusion. Overall, the pooled mean diameter of the PV (PVD) was 10.09 mm (95% CI: 9.56-10.62). Significant differences in diameter were found between pediatric (6.60 mm; 95% CI: 5.38-7.82) and adult (10.72 mm; 95% CI: 10.25-11.19) subjects. Additionally, there was a significantly larger PVD measurement from computed tomography (CT) than other imaging modalities: CT, 13.28 mm (95% CI: 11.71-14.84); magnetic resonance imaging (MRI), 10.50 mm (95% CI: 9.35-11.66) and ultrasound (US), 9.81 mm (95% CI: 9.47-10.16). The mean diameters of the LPV and RPV were 8.27 mm (95% CI: 6.78-9.77) and 8.33 mm (95% CI: 6.70-9.95), respectively. Mean PV length in adults is 48.63 mm (95% CI: 35.63-61.64). Mean CSA of the PV was 1.09 cm.
CONCLUSIONS
The study obtained aim to improve the understanding of portal vein anatomy, especially with relevance to surgical interventions of the liver in both pediatric and adult patients. Measurements from ultrasound imaging closely approximates the generated pooled PVD mean for pediatric and adult patients. CT imaging, however, significantly exceeded the established 13 mm threshold for adults. For pediatric patients, a threshold of 8 mm is proposed as a diagnostic upper limit for a normal PVD. Although not significant, the PVD decreased from the portal confluence towards its bifurcation.
Topics: Humans; Adult; Child; Portal Vein; Liver Diseases; Tomography, X-Ray Computed; Magnetic Resonance Imaging
PubMed: 37742371
DOI: 10.1016/j.ejrad.2023.111016