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Annals of the Royal College of Surgeons... May 2017A 43-year-old man had a peritoneovenous shunt inserted for the treatment of chylous ascites secondary to myelofibrosis. Despite being on anticoagulation for superior...
A 43-year-old man had a peritoneovenous shunt inserted for the treatment of chylous ascites secondary to myelofibrosis. Despite being on anticoagulation for superior mesenteric vein thrombosis, he developed shunt dysfunction within two weeks of insertion. Superior venacavography showed multiple filling defects in the right axillary vein, no filling of the right brachiocephalic and right subclavian vein, and thrombotic occlusion of the internal jugular veins bilaterally. The shunt was removed 11 days after insertion, and there was extensive thrombosis of the venous end of the shunt and the compressible pump chamber. Shunt thrombosis is known to occur but remains a rare complication, with 87% of such obstructions being due to a thrombus at the tip of the venous end of the shunt. Extensive thrombosis of the shunt (as in the present case) is very rare.
Topics: Adult; Chylous Ascites; Humans; Male; Peritoneovenous Shunt; Postoperative Complications; Prosthesis Failure; Venous Thrombosis
PubMed: 28462645
DOI: 10.1308/rcsann.2017.0058 -
Hamostaseologie Apr 2024Splanchnic or visceral vein thromboses (VVTs) are atypical thrombotic entities and include thrombosis of the portal vein, hepatic veins (Budd-Chiari syndrome),... (Review)
Review
Splanchnic or visceral vein thromboses (VVTs) are atypical thrombotic entities and include thrombosis of the portal vein, hepatic veins (Budd-Chiari syndrome), mesenteric veins, and splenic vein. All VVTs have in common high 30-day mortality up to 20% and it seems to be difficult to diagnose VVT early because of their rarity and their wide spectrum of unspecific symptoms. VVTs are often associated with myeloproliferative neoplasia, thrombophilia, and liver cirrhosis. VVT is primarily diagnosed by sonography and/or computed tomography. In contrast to venous thromboembolism, D-dimer testing is neither established nor helpful. Anticoagulation is the first-line therapy in patients with stable circulation and no evidence of organ complications. Anticoagulation improves significantly recanalization rates and stops the progress of thrombosis. Low-molecular-weight heparin, vitamin K antagonists, as well as direct-acting oral anticoagulants are possible anticoagulants, but it is noteworthy to be aware that all recommendations supporting the off-label use of anticoagulants are based on poor evidence and consist predominantly of case series, observational studies, or studies with small case numbers. When choosing a suitable anticoagulation, the individual risk of bleeding and thrombosis must be weighted very carefully. In cases of bleeding, bowel infarction, or other complications, the optimal therapy should be determined on a case-by-case basis by an experienced multidisciplinary team involving a surgeon. Besides anticoagulation, there are therapeutic options including thrombectomy, balloon angioplasty, stenting, transjugular placement of an intrahepatic portosystemic shunt, liver transplantation, and ischemic bowel resection. This article gives an overview of current diagnostic and therapeutic strategies.
Topics: Humans; Anticoagulants; Venous Thrombosis; Practice Guidelines as Topic; Viscera; Budd-Chiari Syndrome; Portal Vein
PubMed: 37992729
DOI: 10.1055/a-2178-6670 -
Digestive Diseases (Basel, Switzerland) 2005The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional treatment resulting in decompression of the portal system by creation of a side-to-side... (Review)
Review
The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional treatment resulting in decompression of the portal system by creation of a side-to-side portosystemic anastomosis. Since its introduction 16 years ago, more than 1,000 publications have appeared demonstrating broad acceptance and increasing clinical use. This review summarizes our present knowledge about technical aspects and complications, follow-up of patients and indications. A technical success rate near 100% and a low occurrence of complications clearly depend on the skills of the operator. The follow-up of the TIPS patient has to assess shunt patency, liver function, hepatic encephalopathy and the possible development of hepatocellular carcinoma. Shunt patency can best be monitored by duplex sonography and can avoid routine radiological revision. Short-term patency may be improved by anticoagulation, while such a treatment does not influence long-term patency. Stent grafts covered with expanded polytetrafluoroethylene show promising long-term patency comparable with that of surgical shunts. With respect to the indications of TIPS, much is known about treatment of variceal bleeding and refractory ascites. The thirteen randomized studies that are available to date show that survival is comparable in patients receiving TIPS or endoscopic treatment for acute or recurrent variceal bleeding. Another group comprises patients with refractory ascites and related complications, such as hepatorenal syndrome and hepatic hydrothorax. It has been demonstrated that TIPS improves these complications. Five randomized studies comparing TIPS with paracentesis and one study comparing TIPS with the peritoneo-venous shunt showed good response of ascites but controversial results on survival. In addition, TIPS has been successfully applied to patients with Budd-Chiari syndrome, portal vein thrombosis, before liver transplantation, and for the treatment of ectopic variceal bleeding.
Topics: Ascites; Budd-Chiari Syndrome; Hemorrhage; Humans; Hypertension, Portal; Liver; Portasystemic Shunt, Transjugular Intrahepatic; Randomized Controlled Trials as Topic; Regional Blood Flow; Survival Analysis; Varicose Veins
PubMed: 15920326
DOI: 10.1159/000084726 -
The Journal of Vascular Access Nov 2021Arteriovenous fistula (AVF) complications are classified based on fistula outcomes. This review aims to update colour Doppler (CD) and pulse wave Doppler (PWD) roles in... (Review)
Review
Arteriovenous fistula (AVF) complications are classified based on fistula outcomes. This review aims to update colour Doppler (CD) and pulse wave Doppler (PWD) roles in managing early and late complications of the native and prosthetic AVF. Vascular access (VA) failure occurs because inflow or outflow stenosis activates Wirchow's triad inducing thrombosis. Therefore, the diagnosis of the tributary artery and outgoing vein stenosis will be the first topic considered. Post-implantation complications occur from the inability to achieve AVF maturation and dialysis suitability due to inflow/outflow stenosis. Late stenosis is usually a sequence of early defects repaired to maintain patency. Less frequently, in the mature AVF or graft, complications are acquired 'de novo'. They derive either from incorrect management of vascular access (haematoma, pseudoaneurysm, prosthesis infection) or wall pathologies (aneurysm, myxoid valve degeneration, kinking, coiling, abnormal dilation from defects of elastic structures). High-resolution transducers (10-20 MHz) allow the characterization of the wall damage, haemodynamic dysfunctions, early and late complications even if phlebography remains the gold standard for the diagnosis for its sensitivity and specificity.
Topics: Aneurysm; Aneurysm, False; Arteriovenous Shunt, Surgical; Humans; Renal Dialysis; Thrombosis; Treatment Outcome; Vascular Patency
PubMed: 34313154
DOI: 10.1177/11297298211018062 -
Acta Neurochirurgica Feb 2021Ventriculoatrial shunts were one of the most common treatments of hydrocephalus in pediatric and adult patients up to about 40 years ago. Thereafter, due to the...
BACKGROUND
Ventriculoatrial shunts were one of the most common treatments of hydrocephalus in pediatric and adult patients up to about 40 years ago. Thereafter, due to the widespread recognition of the severe cardiac and renal complications associated with ventriculoatrial shunts, they are almost exclusively implanted when other techniques fail. However, late infection or atrial thrombi of previously implanted shunts require removal of the atrial catheter several decades after implantation. Techniques derived from management of central venous access catheters can avoid cardiothoracic surgery in such instances.
METHODS
We retrospectively investigated all the patients requiring removal of a VA shunt for complications treated in the last 5 years in our institution.
RESULTS
We identified two patients that were implanted 28 and 40 years earlier. Both developed endocarditis with a large atrial thrombus and were successfully treated endovascularly. The successful percutaneous removal was achieved by applying, for the first time in this setting, the endoluminal dilation technique as proposed by Hong. After ventriculoatrial shunt removal and its substitution with an external drainage, both patients where successfully weaned from the need for a shunt and their infection resolved.
CONCLUSION
Patients carrying a ventriculoatrial shunt are now rarely seen and awareness of long-term ventriculoatrial shunt complications is decreasing. However, these complications must be recognized and treated by shunt removal. Endovascular techniques are appropriate even in the presence of overt endocarditis, atrial thrombi, and tight adherence to the endocardial wall. Moreover, weaning from shunt dependence is possible even decades after shunting.
Topics: Arachnoid Cysts; Cardiac Catheters; Central Venous Catheters; Device Removal; Endovascular Procedures; Female; Heart Atria; Humans; Hydrocephalus; Male; Middle Aged; Retrospective Studies; Thromboembolism; Upper Extremity Deep Vein Thrombosis; Ventriculoperitoneal Shunt
PubMed: 33330950
DOI: 10.1007/s00701-020-04675-1 -
Alimentary Pharmacology & Therapeutics Mar 2006Treatment options for patients with portal vein thrombosis are limited.
BACKGROUND
Treatment options for patients with portal vein thrombosis are limited.
AIM
To evaluate the feasibility and efficacy of transjugular intrahepatic portosystemic shunt for portal vein thrombosis with/without cavernomatous transformation.
METHODS
A survey of such patients, referred for transjugular intrahepatic portosystemic shunt between 1994 and 2005, was performed. Success rates, complications, transjugular intrahepatic portosystemic shunt patency and clinical progression were examined.
RESULTS
Transjugular intrahepatic portosystemic shunt was attempted in 28 patients (13 cirrhotics). Indications were: presurgery/transplantation (2), worsening of ascites (2), variceal bleeding (15 - 8 elective), refractory ascites (3), portal biliopathy (3) and portal vein thrombosis complicating Budd-Chiari syndrome (2). Transjugular intrahepatic portosystemic shunt was placed successfully in 19 of 28 (73%); 23 of 28 had complete portal vein thrombosis and 9 of 23 had cavernous transformation and transjugular intrahepatic portosystemic shunt was successfully placed in six of these. In the 19 patients with transjugular intrahepatic portosystemic shunt, the mean follow-up was 18.1 months (range 5-70): six patients had stent revisions; three had liver transplantation, one died of bleeding. Most cirrhotic patients had an improvement in the Child-Pugh score. In the failed transjugular intrahepatic portosystemic shunt group, two of nine died, and three had further bleeding.
CONCLUSIONS
Transjugular intrahepatic portosystemic shunt should be considered for selected patients with symptomatic complete portal vein thrombosis with/without cavernous transformation, as clinical improvement and less rebleeding occur when transjugular intrahepatic portosystemic shunt placement is successful.
Topics: Adolescent; Adult; Aged; Anticoagulants; Cohort Studies; Emergencies; Feasibility Studies; Female; Humans; Hypertension, Portal; Male; Middle Aged; Portal Vein; Portasystemic Shunt, Surgical; Radiography; Stents; Treatment Failure; Treatment Outcome; Venous Thrombosis
PubMed: 16556179
DOI: 10.1111/j.1365-2036.2006.02820.x -
Clinical and Applied... Apr 2018The objective of this literature review was to estimate the incidence of thrombosis and thromboembolism associated with the superior cavopulmonary anastomosis (SCPA)... (Review)
Review
The objective of this literature review was to estimate the incidence of thrombosis and thromboembolism associated with the superior cavopulmonary anastomosis (SCPA) procedure and its variants and to examine current thromboprophylaxis regimens utilized. MEDLINE and EMBASE were searched from inception to August 2017 for all prospective and retrospective cohort studies explicitly reporting incidence of thrombosis, thromboembolism, or shunt occlusion in neonates, infants, and children undergoing 1 or more variants of the SCPA procedure. End points included thrombotic events and thromboembolic events (strokes and pulmonary embolisms) as primary outcomes, and overall mortality as a secondary outcome, at the last available follow-up time point. Of 1303 unique references identified, 13 cohort studies were deemed eligible. Reported incidence of thrombosis and thromboembolic events ranged from 0% to 28.0% and from 0% to 12.5%, respectively. Reported incidence of major bleeding events ranged from 0% to 2.9%. Reported overall mortality ranged from 2.5% to 50.5% across studies. Thromboprophylaxis protocols varied across institutions and studies, most commonly involving unfractionated heparin (UFH), warfarin, enoxaparin, acetylsalicylic acid (ASA), or combinations of ASA and warfarin, ASA and low-molecular-weight heparin (LMWH), UFH and LMWH, and UFH and ASA; several studies did not specify a protocol. Due to substantial variability in reported event rates, no clear correlation was identified between prophylaxis protocols and postoperative thrombotic complications. Despite guidance recommending postoperative UFH as standard practice, thromboprophylaxis protocols varied across institutions and studies. More robust trials evaluating different thromboprophylaxis regimens for the management of these patients are warranted.
Topics: Disease Management; Heart Bypass, Right; Humans; Incidence; Thromboembolism; Thrombosis
PubMed: 29277101
DOI: 10.1177/1076029617739702 -
Shock (Augusta, Ga.) Jan 2022The pathomechanisms of hypoxemia and treatment strategies for type H and type L acute respiratory distress syndrome (ARDS) in severe acute respiratory syndrome... (Review)
Review
BACKGROUND
The pathomechanisms of hypoxemia and treatment strategies for type H and type L acute respiratory distress syndrome (ARDS) in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced coronavirus disease 2019 (COVID-19) have not been elucidated.
MAIN TEXT
SARS-CoV-2 mainly targets the lungs and blood, leading to ARDS, and systemic thrombosis or bleeding. Angiotensin II-induced coagulopathy, SARS-CoV-2-induced hyperfibrin(ogen)olysis, and pulmonary and/or disseminated intravascular coagulation due to immunothrombosis contribute to COVID-19-associated coagulopathy. Type H ARDS is associated with hypoxemia due to diffuse alveolar damage-induced high right-to-left shunts. Immunothrombosis occurs at the site of infection due to innate immune inflammatory and coagulofibrinolytic responses to SARS-CoV-2, resulting in microvascular occlusion with hypoperfusion of the lungs. Lung immunothrombosis in type L ARDS results from neutrophil extracellular traps containing platelets and fibrin in the lung microvasculature, leading to hypoxemia due to impaired blood flow and a high ventilation/perfusion (VA/Q) ratio. COVID-19-associated ARDS is more vascular centric than the other types of ARDS. D-dimer levels have been monitored for the progression of microvascular thrombosis in COVID-19 patients. Early anticoagulation therapy in critical patients with high D-dimer levels may improve prognosis, including the prevention and/or alleviation of ARDS.
CONCLUSIONS
Right-to-left shunts and high VA/Q ratios caused by lung microvascular thrombosis contribute to hypoxemia in type H and L ARDS, respectively. D-dimer monitoring-based anticoagulation therapy may prevent the progression to and/or worsening of ARDS in COVID-19 patients.
Topics: Anticoagulants; Biomarkers; Blood Platelets; COVID-19; Extracellular Traps; Fibrin; Fibrin Fibrinogen Degradation Products; Fibrinolysis; Hemostasis; Humans; Hypoxia; Lung; Microvessels; Phenotype; Respiratory Distress Syndrome; SARS-CoV-2; Thromboinflammation; Thrombosis; COVID-19 Drug Treatment
PubMed: 34172612
DOI: 10.1097/SHK.0000000000001825 -
World Journal of Gastroenterology Jun 2015Portal vein thrombosis (PVT) is encountered in liver cirrhosis, particularly in advanced disease. It has been a feared complication of cirrhosis, attributed to... (Review)
Review
Portal vein thrombosis (PVT) is encountered in liver cirrhosis, particularly in advanced disease. It has been a feared complication of cirrhosis, attributed to significant worsening of liver disease, poorer clinical outcomes and potential inoperability at liver transplantation; also catastrophic events such as acute intestinal ischaemia. Optimal management of PVT has not yet been addressed in any consensus publication. We review current literature on PVT in cirrhosis; its prevalence, pathophysiology, diagnosis, impact on the natural history of cirrhosis and liver transplantation, and management. Studies were identified by a search strategy using MEDLINE and Google Scholar. The incidence of PVT increases with increasing severity of liver disease: less than 1% in well-compensated cirrhosis, 7.4%-16% in advanced cirrhosis. Prevalence in patients undergoing liver transplantation is 5%-16%. PVT frequently regresses instead of uniform thrombus progression. PVT is not associated with increased risk of mortality. Optimal management has not been addressed in any consensus publication. We propose areas for future research to address unresolved clinical questions.
Topics: Anticoagulants; Disease Progression; Humans; Incidence; Liver Circulation; Liver Cirrhosis; Liver Transplantation; Portal Vein; Portasystemic Shunt, Transjugular Intrahepatic; Prevalence; Prognosis; Risk Factors; Thrombolytic Therapy; Venous Thrombosis
PubMed: 26078553
DOI: 10.3748/wjg.v21.i22.6769 -
Alimentary Pharmacology & Therapeutics Nov 2009Portal vein thrombosis (PVT) is an important cause of portal hypertension. It may occur as such with or without associated cirrhosis and hepatocellular carcinoma.... (Review)
Review
BACKGROUND
Portal vein thrombosis (PVT) is an important cause of portal hypertension. It may occur as such with or without associated cirrhosis and hepatocellular carcinoma. Information on its management is scanty.
AIM
To provide an update on the modern management of portal vein thrombosis. Information on portal vein thrombosis in patients with and without cirrhosis and hepatocellular carcinoma is also updated.
METHODS
A pubmed search was performed to identify the literature using search items portal vein thrombosis-aetiology and treatment and portal vein thrombosis in cirrhosis and hepatocellular carcinoma.
RESULTS
Portal vein thrombosis occurs because of local inflammatory conditions in the abdomen and prothrombotic factors. Acute portal vein thrombosis is usually symptomatic when associated with cirrhosis and/or superior mesenteric vein thrombosis. Anticoagulation should be given for 3-6 months if detected early. If prothrombotic factors are identified, anticoagulation should be given lifelong. Chronic portal vein thrombosis usually presents with well tolerated upper gastrointestinal bleed. It is diagnosed by imaging, which demonstrates a portal cavernoma in place of a portal vein. Anticoagulation does not have a definite role, but bleeds can be treated with endotherapy or shunt surgery. Rarely liver transplantation may be considered.
CONCLUSION
Role of anticoagulation in chronic portal vein thrombosis needs to be further studied.
Topics: Adult; Anticoagulants; Carcinoma, Hepatocellular; Child; Humans; Hypertension, Portal; Liver Cirrhosis; Liver Neoplasms; Portal Vein; Thrombectomy; Thrombolytic Therapy; Venous Thrombosis
PubMed: 19678814
DOI: 10.1111/j.1365-2036.2009.04116.x