Skip to main content

Advertisement

SpringerLink
Log in

Optimal Management of Portal Vein Thrombosis in Patients with Liver Cirrhosis: a Review

  • Portal Hypertension (K Brown, Section Editor)
  • Published:
Current Hepatology Reports Aims and scope Submit manuscript

Abstract

Portal vein thrombosis (PVT) is a fairly common complication of cirrhosis, especially in patients with advanced liver disease and reduced portal vein flow velocity. Prospective studies have shown that its occurrence parallels rather than causes the progression of liver disease and that spontaneous regression is a frequent finding. PVT occurrence is associated with an increased mortality after liver transplantation. Treatment options include anticoagulation and insertion of a transjugular intrahepatic portosystemic shunt. Anticoagulation with vitamin K antagonists or low-molecular-weight heparins achieves partial or complete portal vein recanalization in most patients. Anticoagulation does not seem to increase the bleeding risk when proper prophylaxis of variceal bleeding is applied. Monitoring of anticoagulation difficulties exist, inherent to the coagulopathy of chronic liver disease. Placement of a transjugular intrahepatic portosystemic shunt is an alternative in selected patients. Trials are underway to evaluate the potential benefit of PVT prophylaxis with low-molecular-weight heparins.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Abbreviations

PVT:

Non-neoplastic portal vein thrombosis

LT:

Liver transplantation

SMV:

Superior mesenteric vein

LMWH:

Low-molecular-weight heparin

EV:

Esophageal varices

PV:

Portal vein

EVB:

Esophageal variceal bleeding

NSBB:

Non-selective beta blockers

EBL:

Endoscopic band ligation

VKA:

Vitamin K antagonists

TIPS:

Transjugular intrahepatic portosystemic shunt

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Chung JW et al. Safety, efficacy, and response predictors of anticoagulation for the treatment of nonmalignant portal-vein thrombosis in patients with cirrhosis: a propensity score matching analysis. Clin Mol Hepatol. 2014;20(4):384–91.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Rodriguez-Castro KI et al. Anticoagulation for the treatment of thrombotic complications in patients with cirrhosis. Liver Int. 2012;32(10):1465–76.

    Article  CAS  PubMed  Google Scholar 

  3. Aldawood A et al. The incidence of venous thromboembolism and practice of deep venous thrombosis prophylaxis in hospitalized cirrhotic patients. Thromb J. 2011;9(1):1.

    Article  PubMed Central  PubMed  Google Scholar 

  4. Zocco MA et al. Thrombotic risk factors in patients with liver cirrhosis: correlation with MELD scoring system and portal vein thrombosis development. J Hepatol. 2009;51(4):682–9.

    Article  PubMed  Google Scholar 

  5. Huard G, Bilodeau M. Management of anticoagulation for portal vein thrombosis in individuals with cirrhosis: a systematic review. Int J Hepatol. 2012;2012:672986.

    Article  PubMed Central  PubMed  Google Scholar 

  6. Nery F et al. Causes and consequences of portal vein thrombosis in 1,243 patients with cirrhosis: results of a longitudinal study. Hepatology. 2015;61(2):660–7. Large cohort study reporting the incidence of PVT and demonstrating the absence of an impact of PVT on liver disease progression.

    Article  CAS  PubMed  Google Scholar 

  7. Qi X et al. Anticoagulation for the treatment of portal vein thrombosis in liver cirrhosis: a systematic review and meta-analysis of observational studies. Eur J Intern Med. 2015;26(1):23–9.

    Article  PubMed  Google Scholar 

  8. Delgado MG et al. Efficacy and safety of anticoagulation on patients with cirrhosis and portal vein thrombosis. Clin Gastroenterol Hepatol. 2012;10(7):776–83. Paper describing the rate of PV recanalization with anticoagulation and establishing that early initiation of anticoagulation is predictive of PV recanalization. Paper also demonstrating that platelet count less than 50 is predictive of hemorrhagic complications.

    Article  PubMed  Google Scholar 

  9. Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med. 2011;365(2):147–56. Paper describing the coagulation abnormalities induced by the cirrhosis.

    Article  CAS  PubMed  Google Scholar 

  10. Valla DC. Thrombosis and anticoagulation in liver disease. Hepatology. 2008;47(4):1384–93. Paper describing the coagulation abnormalities induced by the cirrhosis.

    Article  CAS  PubMed  Google Scholar 

  11. Plessier A, Rautou PE, Valla DC. Management of hepatic vascular diseases. J Hepatol. 2012;56 Suppl 1:S25–38.

    Article  CAS  PubMed  Google Scholar 

  12. Yerdel MA et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69(9):1873–81.

    Article  CAS  PubMed  Google Scholar 

  13. Englesbe MJ et al. Portal vein thrombosis and liver transplant survival benefit. Liver Transpl. 2010;16(8):999–1005.

    Article  PubMed Central  PubMed  Google Scholar 

  14. Francoz C et al. Splanchnic vein thrombosis in candidates for liver transplantation: usefulness of screening and anticoagulation. Gut. 2005;54(5):691–7.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  15. Valla DC, Rautou PE. The coagulation system in patients with end-stage liver disease. Liver Int. 2015;35 Suppl 1:139–44. Paper describing the coagulation abnormalities induced by the cirrhosis.

    Article  CAS  PubMed  Google Scholar 

  16. Tripodi A et al. Evidence that low protein C contributes to the procoagulant imbalance in cirrhosis. J Hepatol. 2013;59(2):265–70. Paper describing the coagulation abnormalities induced by the cirrhosis.

    Article  CAS  PubMed  Google Scholar 

  17. Northup PG et al. Coagulopathy does not fully protect hospitalized cirrhosis patients from peripheral venous thromboembolism. Am J Gastroenterol. 2006;101(7):1524–8. quiz 1680.

    Article  PubMed  Google Scholar 

  18. Dabbagh O et al. Coagulopathy does not protect against venous thromboembolism in hospitalized patients with chronic liver disease. Chest. 2010;137(5):1145–9.

    Article  PubMed  Google Scholar 

  19. Martinelli I. High levels of factor VIII and risk of extra-hepatic portal vein obstruction. J Hepatol. 2009;50(5):916–22. Paper describing the coagulation abnormalities induced by the cirrhosis.

    Article  CAS  PubMed  Google Scholar 

  20. Amitrano L et al. Inherited coagulation disorders in cirrhotic patients with portal vein thrombosis. Hepatology. 2000;31(2):345–8.

    Article  CAS  PubMed  Google Scholar 

  21. Mangia A et al. Causes of portal venous thrombosis in cirrhotic patients: the role of genetic and acquired factors. Eur J Gastroenterol Hepatol. 2005;17(7):745–51.

    Article  CAS  PubMed  Google Scholar 

  22. Saugel B, et al. Thrombophilic factor analysis in cirrhotic patients with portal vein thrombosis. J Thromb Thrombolysis, 2014.

  23. Montalto P et al. Bacterial infection in cirrhosis impairs coagulation by a heparin effect: a prospective study. J Hepatol. 2002;37(4):463–70.

    Article  CAS  PubMed  Google Scholar 

  24. Pache I, Bilodeau M. Severe haemorrhage following abdominal paracentesis for ascites in patients with liver disease. Aliment Pharmacol Ther. 2005;21(5):525–9.

    Article  CAS  PubMed  Google Scholar 

  25. Garcia-Pagan JC, Hernandez-Guerra M, Bosch J. Extrahepatic portal vein thrombosis. Semin Liver Dis. 2008;28(3):282–92.

    Article  PubMed  Google Scholar 

  26. DeLeve LD, Valla DC, Garcia-Tsao G. Vascular disorders of the liver. Hepatology. 2009;49(5):1729–64.

    Article  CAS  PubMed  Google Scholar 

  27. Maruyama H et al. De novo portal vein thrombosis in virus-related cirrhosis: predictive factors and long-term outcomes. Am J Gastroenterol. 2013;108(4):568–74.

    Article  PubMed  Google Scholar 

  28. Hung HH et al. Efficacy of non-selective beta-blockers as adjunct to endoscopic prophylactic treatment for gastric variceal bleeding: a randomized controlled trial. J Hepatol. 2012;56(5):1025–32.

    Article  CAS  PubMed  Google Scholar 

  29. Wu CY, Yeh HZ, Chen GH. Pharmacologic efficacy in gastric variceal rebleeding and survival: including multivariate analysis. J Clin Gastroenterol. 2002;35(2):127–32.

    Article  PubMed  Google Scholar 

  30. D'Amico G, De Franchis R. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology. 2003;38(3):599–612.

    Article  PubMed  Google Scholar 

  31. Villa E et al. Enoxaparin prevents portal vein thrombosis and liver decompensation in patients with advanced cirrhosis. Gastroenterology. 2012;143(5):1253–60. Paper demonstrating a protective effect of prophylactic anticoagulation in cirrhotic patients in order to decrease decompensation.

    Article  CAS  PubMed  Google Scholar 

  32. Doenecke A et al. Pre-existent portal vein thrombosis in liver transplantation: influence of pre-operative disease severity. Clin Transplant. 2010;24(1):48–55.

    Article  CAS  PubMed  Google Scholar 

  33. Borchert DH. Cavoportal hemitransposition for the simultaneous thrombosis of the caval and portal systems—a review of the literature. Ann Hepatol. 2008;7(3):200–11.

    PubMed  Google Scholar 

  34. Selvaggi G et al. Ten-year experience in porto-caval hemitransposition for liver transplantation in the presence of portal vein thrombosis. Am J Transplant. 2007;7(2):454–60.

    Article  CAS  PubMed  Google Scholar 

  35. Hibi T et al. When and why portal vein thrombosis matters in liver transplantation: a critical audit of 174 cases. Ann Surg. 2014;259(4):760–6.

    Article  PubMed  Google Scholar 

  36. Amitrano L et al. Safety and efficacy of anticoagulation therapy with low molecular weight heparin for portal vein thrombosis in patients with liver cirrhosis. J Clin Gastroenterol. 2010;44(6):448–51.

    CAS  PubMed  Google Scholar 

  37. Senzolo M et al. Prospective evaluation of anticoagulation and transjugular intrahepatic portosystemic shunt for the management of portal vein thrombosis in cirrhosis. Liver Int. 2012;32(6):919–27. Study demonstrating a positive impact of TIPS in PVT management.

    Article  CAS  PubMed  Google Scholar 

  38. Amitrano L et al. Risk factors and clinical presentation of portal vein thrombosis in patients with liver cirrhosis. J Hepatol. 2004;40(5):736–41.

    Article  PubMed  Google Scholar 

  39. Tripodi A. Thrombin generation in patients with cirrhosis: the role of platelets. Hepatology. 2006;44(2):440–5. Paper describing the coagulation abnormalities induced by the cirrhosis.

    Article  CAS  PubMed  Google Scholar 

  40. Cerini F, et al. Impact of anticoagulation on upper-gastrointestinal bleeding in cirrhosis. A retrospective multicenter study. Hepatology, 2015. Paper demonstrating that anticoagulation therapy is not a predictive factor for early failure to control bleeding or mortality in cirrhotic patients presenting with upper gastrointestinal bleeding

  41. Garcia-Tsao G et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922–38.

    Article  CAS  PubMed  Google Scholar 

  42. Petersen JL et al. Efficacy and bleeding complications among patients randomized to enoxaparin or unfractionated heparin for antithrombin therapy in non-ST-Segment elevation acute coronary syndromes: a systematic overview. Jama. 2004;292(1):89–96.

    Article  CAS  PubMed  Google Scholar 

  43. Bajaj JS, Franco J. Endoscopic band ligation of esophageal varices in patients on anticoagulation. J Clin Gastroenterol. 2008;42(7):782–5.

    Article  PubMed  Google Scholar 

  44. Lisman T et al. Established and new-generation antithrombotic drugs in patients with cirrhosis—possibilities and caveats. J Hepatol. 2013;59(2):358–66.

    Article  CAS  PubMed  Google Scholar 

  45. Tripodi A et al. Hypercoagulability in cirrhosis: causes and consequences. J Thromb Haemost. 2011;9(9):1713–23. Paper describing the coagulation abnormalities induced by the cirrhosis.

    Article  CAS  PubMed  Google Scholar 

  46. Kirkwood TB. Calibration of reference thromboplastins and standardisation of the prothrombin time ratio. Thromb Haemost. 1983;49(3):238–44.

    CAS  PubMed  Google Scholar 

  47. Northup PG, Intagliata NM. Anticoagulation in cirrhosis patients: what don’t we know? Liver Int. 2011;31(1):4–6.

    Article  PubMed  Google Scholar 

  48. Bechmann LP et al. Low-molecular-weight heparin in patients with advanced cirrhosis. Liver Int. 2011;31(1):75–82.

    Article  CAS  PubMed  Google Scholar 

  49. Martinez M, A Tandra, R Vuppalanchi. Re: HEP-14-1844.R1—treatment of portal vein thrombosis by non-traditional anticoagulation. Hepatology, 2014.

  50. Caldeira D et al. Risk of drug-induced liver injury with the new oral anticoagulants: systematic review and meta-analysis. Heart. 2014;100(7):550–6.

    Article  CAS  PubMed  Google Scholar 

  51. Raschi E, et al. Liver injury with novel oral anticoagulants: assessing post-marketing reports in the US Food and Drug Administration Adverse Event Reporting System. Br J Clin Pharmacol, 2015.

  52. Luca A et al. Natural course of extrahepatic nonmalignant partial portal vein thrombosis in patients with cirrhosis. Radiology. 2012;265(1):124–32.

    Article  PubMed  Google Scholar 

  53. Han G et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosis. J Hepatol. 2011;54(1):78–88.

    Article  PubMed  Google Scholar 

  54. Luca A. Short- and long-term effects of the transjugular intrahepatic portosystemic shunt on portal vein thrombosis in patients with cirrhosis. Gut. 2011;60(6):846–52. Paper describing the effects of TIPS on PVT in patients with cirrhosis.

    Article  PubMed  Google Scholar 

  55. Senzolo M et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation. Aliment Pharmacol Ther. 2006;23(6):767–75.

    Article  CAS  PubMed  Google Scholar 

  56. Bauer J et al. The role of TIPS for portal vein patency in liver transplant patients with portal vein thrombosis. Liver Transpl. 2006;12(10):1544–51.

    Article  PubMed  Google Scholar 

  57. Jacobi D et al. Transjugular intrahepatic portosystemic shunt for the treatment of portal hypertension secondary to non-cirrhotic perisinusoidal hepatic fibrosis. Eur J Gastroenterol Hepatol. 2006;18(5):549–51.

    Article  PubMed  Google Scholar 

  58. Luo X, et al. Advanced cirrhosis combined with portal vein thrombosis: a randomized trial of tips versus endoscopic band ligation plus propranolol for the prevention of recurrent esophageal variceal bleeding. Radiology, 2015: p. 141252.

  59. D'Avola D et al. Efficacy of transjugular intrahepatic portosystemic shunt to prevent total portal vein thrombosis in cirrhotic patients awaiting for liver transplantation. Transplant Proc. 2012;44(9):2603–5.

    Article  PubMed  Google Scholar 

  60. Guerrini GP et al. Impact of tips preliver transplantation for the outcome posttransplantation. Am J Transplant. 2009;9(1):192–200.

    Article  CAS  PubMed  Google Scholar 

  61. Clavien PA et al. Liver transplantation complicated by misplaced TIPS in the portal vein. Ann Surg. 1998;227(3):440–5.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Geneviève Huard and Marc Bilodeau declare that they have no conflict of interest.

Julien Bissonnette has received the Canadian Association for the Study of the Liver/Gilead Clinical Fellowship grant.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

  1. Liver Unit, Hôpital Saint-Luc, Centre Hospitalier de l’Université de Montréal, 264, Boulevard René-Lévesque Est, Pavillon Édouard-Asselin, Bureau 318, Montréal, QC, H2X 1P1, Canada

    Geneviève Huard, Julien Bissonnette & Marc Bilodeau

Authors
  1. Geneviève Huard
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Julien Bissonnette
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marc Bilodeau
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Geneviève Huard.

Additional information

This article is part of the Topical Collection on Portal Hypertension

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Huard, G., Bissonnette, J. & Bilodeau, M. Optimal Management of Portal Vein Thrombosis in Patients with Liver Cirrhosis: a Review. Curr Hepatology Rep 14, 203–211 (2015). https://doi.org/10.1007/s11901-015-0273-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11901-015-0273-7

Keywords

Search

Navigation