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World Journal of Gastroenterology Jan 2010Portal 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... (Review)
Review
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.
Topics: Anticoagulants; Humans; Portal Vein; Portasystemic Shunt, Surgical; Prognosis; Thrombosis; Treatment Outcome; Ultrasonography
PubMed: 20066733
DOI: 10.3748/wjg.v16.i2.143 -
Alimentary Pharmacology & Therapeutics Feb 2010As current imaging techniques in cirrhosis allow detection of asymptomatic portal vein thrombosis during routine ultrasonography, more patients with cirrhosis are... (Review)
Review
BACKGROUND
As current imaging techniques in cirrhosis allow detection of asymptomatic portal vein thrombosis during routine ultrasonography, more patients with cirrhosis are diagnosed with portal vein thrombosis. Although a consensus on noncirrhotic extra-hepatic portal vein thrombosis has been published, no such consensus exists for portal vein thrombosis with cirrhosis.
AIM
To perform a systematic review of nonmalignant portal vein thrombosis in cirrhosis in terms of prevalence, pathogenesis, diagnosis, clinical course and management.
METHODS
Studies were identified by a search strategy using MEDLINE and EMBASE.
RESULTS
Portal vein thrombosis is encountered in 10-25% of cirrhotics. In terms of pathophysiology, cirrhosis is no longer considered a hypocoagulable state; rather than a bleeding risk in cirrhosis, various clinical studies support a thrombotic potential. Clinical findings of portal vein thrombosis in cirrhosis vary from asymptomatic disease to a life-threatening condition at first presentation. Optimal management of portal vein thrombosis in cirrhosis is currently not addressed in any consensus publication. Treatment strategies most often include the use of anticoagulation, while thrombectomy and transjugular intrahepatic portosystemic shunts are considered second-line options.
CONCLUSIONS
Portal vein thrombosis in cirrhosis has many unresolved issues, which are often the critical problems clinicians encounter in their everyday practice. We propose a possible research agenda to address these unresolved issues.
Topics: Humans; Liver Cirrhosis; Portal Vein; Prevalence; Ultrasonography, Doppler, Duplex; Venous Thrombosis
PubMed: 19863496
DOI: 10.1111/j.1365-2036.2009.04182.x -
The Cochrane Database of Systematic... Jan 2016Guidelines recommend routine arteriovenous (AV) graft and fistula surveillance (technology-based screening) in addition to clinical monitoring (physical examination) for... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Guidelines recommend routine arteriovenous (AV) graft and fistula surveillance (technology-based screening) in addition to clinical monitoring (physical examination) for early identification and pre-emptive correction of a stenosis before the access becomes dysfunctional. However, consequences on patient-relevant outcomes of pre-emptive correction of a stenosis in a functioning access as opposed to deferred correction, i.e. correction postponed to when the access becomes dysfunctional, are uncertain.
OBJECTIVES
We aimed to evaluate 1) whether pre-emptive correction of an AV access stenosis improves clinically relevant outcomes; 2) whether the effects of pre-emptive correction of an AV access stenosis differ by access type (fistula versus graft), aim (primary and secondary prophylaxis), and surveillance method for primary prophylaxis (Doppler ultrasound for the screening of functional and anatomical changes versus measurement of the flow in the access); and 3) whether other factors (dialysis duration, access location, configuration or materials, algorithm for referral for intervention, intervention strategies (surgical versus radiological or other), or study design) explain the heterogeneity that might exist in the effect estimates.
SEARCH METHODS
We searched the Cochrane Kidney and Transplant Specialised Register to 30 November 2015 using search terms relevant to this review.
SELECTION CRITERIA
We included all studies of any access surveillance method for early identification and pre-emptive treatment of an AV access stenosis.
DATA COLLECTION AND ANALYSIS
We extracted data on potentially remediable and irremediable failure of the access (i.e. thrombosis and access loss respectively); infection and mortality; and resource use (hospitalisation, diagnostic and intervention procedures). Analysis was by a random effects model and results expressed as risk ratio (RR), hazard ratio (HR) or incidence rate ratio (IRR) with 95% confidence intervals (CI).
MAIN RESULTS
We identified 14 studies (1390 participants), nine enrolled adults without a known access stenosis (primary prophylaxis; three studies including people using fistulas) and five enrolled adults with a documented stenosis in a non-dysfunctional access (secondary prophylaxis; three studies in people using fistulas). Study follow-up ranged from 6 to 38 months, and study size ranged from 58 to 189 participants. In low- to moderate-quality evidence (based on GRADE criteria) in adults treated with haemodialysis, relative to no surveillance and deferred correction, surveillance with pre-emptive correction of an AV stenosis reduced the risk of thrombosis (RR 0.79, 95% CI 0.65 to 0.97; I² = 30%; 18 study comparisons, 1212 participants), but had imprecise effect on the risk of access loss (RR 0.81, 95% CI 0.65 to 1.02; I² = 0%; 11 study comparisons, 972 participants). In analyses subgrouped by access type, pre-emptive stenosis correction did not reduce the risk of thrombosis (RR 0.95, 95% CI 0.8 to 1.12; I² = 0%; 11 study comparisons, 697 participants) or access loss in grafts (RR 0.9, 95% CI 0.71 to 1.15; I² = 0%; 7 study comparisons; 662 participants), but did reduce the risk of thrombosis (RR 0.5, 95% CI 0.35 to 0.71; I² = 0%; 7 study comparisons, 515 participants) and the risk of access loss in fistulas (RR 0.5, 95% CI 0.29 to 0.86; I² = 0%; 4 studies; 310 participants). Three of the four studies reporting access loss data in fistulas (199 participants) were conducted in the same centre. Insufficient data were available to assess whether benefits vary by prophylaxis aim in fistulas (i.e. primary and secondary prophylaxis). Although the magnitude of the effects of pre-emptive stenosis correction was considerable for patient-centred outcomes, results were either heterogeneous or imprecise. While pre-emptive stenosis correction may reduce the rates of hospitalisation (IRR 0.54, 95% CI 0.31 to 0.93; I² = 67%; 4 study comparisons, 219 participants) and use of catheters (IRR 0.58, 95% CI 0.35 to 0.98; I² = 53%; 6 study comparisons, 394 participants), it may also increase the rates of diagnostic procedures (IRR 1.78, 95% CI 1.18 to 2.67; I² = 62%; 7 study comparisons, 539 participants), infection (IRR 1.74, 95% CI 0.78 to 3.91; I² = 0%; 3 studies, 248 participants) and mortality (RR 1.38, 95% CI 0.91 to 2.11; I² = 0%; 5 studies, 386 participants).In general, risk of bias was high or unclear in most studies for many domains we assessed. Four studies were published after 2005 and only one had evidence of registration within a trial registry. No study reported information on authorship and/or involvement of the study sponsor in data collection, analysis, and interpretation.
AUTHORS' CONCLUSIONS
Pre-emptive correction of a newly identified or known stenosis in a functional AV access does not improve access longevity. Although pre-emptive stenosis correction may be promising in fistulas existing evidence is insufficient to guide clinical practice and health policy. While pre-emptive stenosis correction may reduce the risk of hospitalisation, this benefit is uncertain whereas there may be a substantial increase (i.e. 80%) in the use of access-related procedures and procedure-related adverse events (e.g. infection, mortality). The net effects of pre-emptive correction on harms and resource use are thus unclear.
Topics: Adult; Arteriovenous Shunt, Surgical; Constriction, Pathologic; Humans; Kidney Failure, Chronic; Primary Prevention; Randomized Controlled Trials as Topic; Renal Dialysis; Secondary Prevention; Thrombosis
PubMed: 26741512
DOI: 10.1002/14651858.CD010709.pub2 -
International Journal of Surgery... Oct 2020Nontumoral portal vein thrombosis (PVT) is present at liver transplantation (LT) in 5-26% of cirrhotic patients, and is known to affect post LT outcomes. Up to 31% of... (Review)
Review
Nontumoral portal vein thrombosis (PVT) is present at liver transplantation (LT) in 5-26% of cirrhotic patients, and is known to affect post LT outcomes. Up to 31% of patients who are found to have PVT at the time of LT, would have had PVT at the time of initial listing, but others develop PVT during the waiting period. Adequate screening and treatment of the PVT on the waiting list for LT is thus essential so that a portoportal anastomoses can be performed at the time of LT. Early PVT (Yerdel Grade I/II) can be usually managed by thrombectomy, whereas Grade III PVT may require a jump graft from the superior mesenteric vein to the graft PV. Complete portomesenteric thrombosis is a huge challenge, and sometimes a cause for denying a LT in these patients, with multivisceral transplant being the only alternative. The presence of spontaneous, or previously surgically created portosytemic shunts like the leinorenal shunt, may serve as a good inflow option (renoportal anastomosis) in these patients to establish a physiological reconstruction. Although challenging, good outcomes are possible in patients with complex PVT if the appropriate surgical technique is chosen to ensure portal inflow and resolution of PHT post LT.
Topics: Female; Humans; Liver Cirrhosis; Liver Transplantation; Male; Mesenteric Veins; Middle Aged; Portal Vein; Thrombectomy; Vascular Surgical Procedures; Venous Thrombosis; Waiting Lists
PubMed: 32387201
DOI: 10.1016/j.ijsu.2020.04.068 -
The Journal of Extra-corporeal... Sep 2006Combined anti-platelet-anticoagulant therapy is increasingly being used to reduce the risk of device-induced thrombosis and thromboembolism. However, direct quantitative...
Combined anti-platelet-anticoagulant therapy is increasingly being used to reduce the risk of device-induced thrombosis and thromboembolism. However, direct quantitative confirmation of the effectiveness of this combination approach is lacking. This study was undertaken to quantify the effects of various combinations of heparin (anticoagulant) and tirofiban (antiplatelet agent) on device-induced thrombosis and thromboembolism using a coronary stent as a prototype device. Adult sheep were implanted with ex vivo carotid-carotid shunts containing replaceable tubing segments in which nitinol stents were deployed. Nine combinations of heparin (average activated clot time = 129, 199, and 355 seconds) and tirofiban (0%, 50%, and 100% platelet inhibition) were tested at random with three replicates per animal. Thrombus weight on the stent at the end of each experiment (1 hour) was measured, and emboli released from the stent were continuously monitored during the experiment using a light scattering microemboli detector. With no tirofiban, increasing the heparin concentration was associated with a decreased endpoint thrombus weight (p < .05) but with a slight (non-significant) increase in the number of downstream thromboemboli. However, the presence of tirofiban decreased both thrombus weight and thromboemboli numbers (p < .05), regardless of the heparin concentration. In the presence of medium or high tirofiban, an increase of heparin from low to medium levels also decreased both thrombus weight and thromboemboli numbers (p < .05). Heparin alone does not provide adequate protection against thromboembolism (and may actually increase it by reducing thrombus cohesive strength). However, the combination of heparin and tirofiban is effective in reducing both thrombus and thromboemboli, and an optimal combination may exist.
Topics: Animals; Anticoagulants; Drug Therapy, Combination; Heparin; In Vitro Techniques; Male; Platelet Aggregation Inhibitors; Sheep; Stents; Thromboembolism; Thrombosis; Tirofiban; Tyrosine
PubMed: 17089509
DOI: No ID Found -
Internal Medicine (Tokyo, Japan) 2020Objective The presence of deep venous thrombosis (DVT) in a cryptogenic stroke (CS) patient with a right-to-left shunt (RLS) may lead to the development of paradoxical...
Objective The presence of deep venous thrombosis (DVT) in a cryptogenic stroke (CS) patient with a right-to-left shunt (RLS) may lead to the development of paradoxical embolism. The aim of the present was to investigate the prevalence of DVT and pulmonary embolism (PE) in CS patients and the clinical features of CS in relation to DVT location and the presence of PE. Methods The medical records of 903 patients with cerebral infarction were retrospectively reviewed. For patients with a diagnosis of CS, contrast saline transcranial color-coded sonography was performed to identify an RLS. DVT and PE were assessed by duplex ultrasonography and/or contrast-enhanced computed tomography. Proximal DVT (P-DVT) was defined as DVT in the popliteal, femoral, or iliac veins, and distal DVT (D-DVT) was defined as DVT at other locations. The patients were divided into three groups: CS with P-DVT and/or PE (P-DVT/PE) group; CS with D-DVT (D-DVT) group; and CS without DVT (no DVT) group. Results Seventy-two (37%) of 194 patients with CS had an RLS. The median time to first DVT examination from stroke onset was three days. Twenty-nine percent of CS patients with an RLS had DVT. The P-DVT/PE group comprised 8.3% of the CS patients with an RLS and included a larger number of patients with multi-territory infarction than the D-DVT group. The D-DVT and P-DVT/PE groups tended to be female and older, while the P-DVT/PE group tended to have pre-stroke disability. Conclusion CS patients, especially those with multi-territory lesions, should be immediately examined for DVT and PE.
Topics: Aged; Aged, 80 and over; Cerebral Infarction; Early Diagnosis; Embolism, Paradoxical; Female; Humans; Male; Middle Aged; Prevalence; Retrospective Studies; Tomography, X-Ray Computed; Venous Thrombosis
PubMed: 32295996
DOI: 10.2169/internalmedicine.3736-19 -
European Journal of Vascular and... Jul 2006Stenoses and thromboses of dialysis grafts and fistulae are common problems in patients with end stage renal disease (ESRD). Timely recognition and treatment of... (Review)
Review
Stenoses and thromboses of dialysis grafts and fistulae are common problems in patients with end stage renal disease (ESRD). Timely recognition and treatment of access-related complications are essential to achieve long-term access function. Minimally invasive percutaneous interventions are techniques of growing importance for the interventional community. While stenoses can typically be treated by balloon angioplasty (PTA), thrombotic lesions may necessitate the combination of mechanical devices and/or thrombolytic agents with ancillary PTA. In this article, interventional treatments for the failing arteriovenous (AV) access are presented and reviewed.
Topics: Angioplasty, Balloon; Arteriovenous Shunt, Surgical; Blood Vessel Prosthesis Implantation; Catheterization, Central Venous; Clinical Trials as Topic; Combined Modality Therapy; Constriction, Pathologic; Fibrinolytic Agents; Graft Occlusion, Vascular; Humans; Kidney Failure, Chronic; Radiography; Renal Dialysis; Stents; Thrombosis; Urokinase-Type Plasminogen Activator; Vascular Patency
PubMed: 16297644
DOI: 10.1016/j.ejvs.2005.10.004 -
World Journal of Gastroenterology Nov 2014Hepatic encephalopathy (HE) is a cognitive disturbance characterized by neuropsychiatric alterations. It occurs in acute and chronic hepatic disease and also in patients...
UNLABELLED
Hepatic encephalopathy (HE) is a cognitive disturbance characterized by neuropsychiatric alterations. It occurs in acute and chronic hepatic disease and also in patients with portosystemic shunts. The presence of these portosystemic shunts allows the passage of nitrogenous substances from the intestines through systemic veins without liver depuration. Therefore, the embolization of these shunts has been performed to control HE manifestations, but the presence of portal vein thrombosis is considered a contraindication. In this presentation we show a cirrhotic patient with severe HE and portal vein thrombosis who was submitted to embolization of a large portosystemic shunt.
CASE REPORT
a 57 years-old cirrhotic patient who had been hospitalized many times for persistent HE and hepatic coma, even without precipitant factors. She had a wide portosystemic shunt and also portal vein thrombosis. The abdominal angiography confirmed the splenorenal shunt and showed other shunts. The larger shunt was embolized through placement of microcoils, and the patient had no recurrence of overt HE. There was a little increase of esophageal and gastric varices, but no endoscopic treatment was needed. Since portosystemic shunts are frequent causes of recurrent HE in cirrhotic patients, portal vein thrombosis should be considered a relative contraindication to perform a shunt embolization. However, in particular cases with many shunts and severe HE, we found that one of these shunts can be safely embolized and this procedure can be sufficient to obtain a good HE recovery. In conclusion, we reported a case of persistent HE due to a wide portosystemic shunt associated with portal vein thrombosis. As the patient had other shunts, she was successfully treated by embolization of the larger shunt.
Topics: Embolization, Therapeutic; Female; Hepatic Encephalopathy; Humans; Liver Circulation; Liver Cirrhosis; Middle Aged; Phlebography; Portal Pressure; Portal Vein; Recurrence; Splenic Vein; Treatment Outcome; Venous Thrombosis
PubMed: 25400477
DOI: 10.3748/wjg.v20.i42.15910 -
Lakartidningen Sep 2022Acute mesenteric venous thrombosis causes impaired mesenteric blood supply which may lead to bowel infarction and, in a longer perspective, severe portal hypertension.... (Review)
Review
Acute mesenteric venous thrombosis causes impaired mesenteric blood supply which may lead to bowel infarction and, in a longer perspective, severe portal hypertension. Early diagnosis, immediate anticoagulation, and active expectancy are critical for the outcome. The patients should be evaluated and treated in a multidisciplinary context, involving gastroenterologists, interventional radiologists, vascular and colorectal surgeons, and consultants in clinical coagulation. Percutaneous thrombectomy, including transjugular intrahepatic portosystemic shunt (TIPS), should be considered in cases with imminent bowel necrosis despite adequate anticoagulation, but can also serve as a complement to surgery. Here we provide a clinical overview of acute mesenteric venous thrombosis, exemplified with authentic patient cases, especially discussing the role for interventional radiology.
Topics: Acute Disease; Anticoagulants; Humans; Mesenteric Ischemia; Portal Vein; Treatment Outcome; Venous Thrombosis
PubMed: 36125253
DOI: No ID Found -
Cardiovascular and Interventional... Feb 2023The purpose of this study was to elicit the relationship of antiplatelet therapy (AP) in maintaining arteriovenous graft (AVG) patency after successful percutaneous...
PURPOSE
The purpose of this study was to elicit the relationship of antiplatelet therapy (AP) in maintaining arteriovenous graft (AVG) patency after successful percutaneous pharmacomechanical thrombectomy ("declot").
MATERIALS AND METHODS
This was an institutional review board-approved retrospective review of AVG declot procedures between July 2019 and August 2020. AVG characteristics, bleeding complications, anticoagulation and antiplatelet medication regimens, and thrombosis free survival were evaluated. Recurrent time-to-event analysis was performed using a Prentice-Williams-Peterson Gap time model was performed to evaluate AVG thrombosis free survival.
RESULTS
A total of 109 declots were technically successful and performed in 63 individual patients. The majority of procedures were performed in upper arm grafts (71%, n = 45). Dual antiplatelet (DAPT) was prescribed after 52 declots (48%), single antiplatelet was prescribed after 36 declots (33%), and anticoagulation was prescribed after 31 declots (28%). Median thrombosis free survival was 37 days (range 1-412 days) in the no antiplatelet group, 84 days (range 1-427 days) in the single antiplatelet group, and 93 days (range 3-407 days) in the DAPT group. Anti-platelet medications trended towards protective of AVG thrombosis in multivariate analysis (hazard ratio 0.84, 95% confidence interval 0.60-1.19); however, this did not reach statistical significance (P = 0.33). A total of 4 major and 5 minor bleeding events occurred.
CONCLUSION
The results of this study support further evaluation of AP therapy in preventing secondary rethrombosis of dialysis AVG.
Topics: Humans; Platelet Aggregation Inhibitors; Graft Occlusion, Vascular; Vascular Patency; Thrombectomy; Thrombosis; Renal Dialysis; Anticoagulants; Retrospective Studies; Arteriovenous Shunt, Surgical; Treatment Outcome
PubMed: 36536145
DOI: 10.1007/s00270-022-03329-2