Long-Term Outcome of Splanchnic Vein Thrombosis in Cirrhosis

Abstract

IntroductionLittle is known about the long-term outcome of cirrhotic patients with splanchnic vein thrombosis (SVT). This prospective cohort study aimed to describe the clinical presentation, bleeding incidence, thrombotic events, and mortality in patients with SVT associated with cirrhosis.MethodsAmong 604 consecutive patients with SVT enrolled over 2 years, 149 had cirrhosis. Major bleeding, thrombotic events, and all-cause mortality were recorded during a 2-year follow-up. In a subgroup, the degree of recanalization with or without anticoagulation therapy, and the correlation between clinical events and liver disease severity were also investigated.ResultsThe most common thrombosis sites were the portal (88%) and mesenteric veins (34%). At presentation, 50% of patients were asymptomatic. Anticoagulation was administered to 92/149 patients for a median of 6.5 months. Vessel recanalization was documented in 47/98 patients with a radiological follow-up. Anticoagulation was associated with a 3.33-fold higher of recanalization rate, and a lower recurrent thrombosis rate, while patients with and without anticoagulation experienced a similar rate of major bleeding episodes. Mortality rates were 6.8 per 100 patient-years for patients with thrombosis completely or partially resolving during the follow-up, and 15.4 per 100 patient-years for those with stable or progressing thrombosis. An impact of SVT on survival was only apparent in patients with more advanced liver disease (Child–Pugh B-C).ConclusionsPatients with SVT and cirrhosis have a substantial long-term risk of recurrent thrombotic events, which is reduced by anticoagulation therapy without any increase in bleeding risk. Anticoagulation can improve the likelihood of vessel recanalization, and is associated with a lower risk of death for decompensated patients.

Mortality in liver transplant recipients with portal vein thrombosis - an updated meta-analysis

“…Patients should therefore not be refused LT, as long as their surgical risk (dictated by additional comorbidities) is acceptable and an adequate transplant benefit can be expected. In the absence of an alternative, effective therapy, candidates for LT with porto‐mesenteric thrombosis nonetheless carry a higher mortality risk while on the waiting list . To sum up, although it is true that mortality after LT is very high in patients with grade 4 PVT, an appropriate transplant benefit may still be achieved in selected cases.…”

Recent developments in the field of vascular liver diseases

“…Apparently, this does not agree with an increasing body of data on the impact of recanalization during anticoagulation therapy. Recanalization during anticoagulant therapy is related to improved event‐free survival after adjustment for the severity of liver disease and portal hypertension, improved liver function tests as well as decreased mortality, particularly in patients with the most severe liver disease . It is frustrating to note that no predictors for the resolution of portal vein thrombus have been identified .…”

“…Not surprisingly multivariate analyses in these retrospective observational studies showed significant differences between patients who received anticoagulants and those who did not. In particular, a lower proportion of past variceal bleeding or cavernoma, lower blood urea levels, a smaller proportion of alcoholics, severe liver disease or cavernoma were found as well as an increased proportion of women or non‐specific beta‐blockers and a higher proportion of involvement of the superior mesenteric vein or multiple venous sites . These factors were not taken into account in the 2017 meta‐analysis …”

“…Recanalization during anticoagulant therapy is related to improved event-free survival after adjustment for the severity of liver disease and portal hypertension, [26][27][28][29][30] improved liver function tests 31,32 as well as decreased mortality, particularly in patients with the most severe liver disease. 29 It is frustrating to note that no predictors for the resolution of portal vein thrombus have been identified. 12,22,23,33 Results on analyses to identify predictors for recanalization on anticoagulation therapy have been varied.…”

“…Since this paper was published, a dozen, mainly retrospective studies have been published, largely confirming these findings in a total of 653 patients receiving anticoagulation, and including 312 patients who received anticoagulants compared to 251 patients who did not. [28][29][30][31][32]35,[64][65][66][67] These recent studies show the high risk of recurrence following discontinuation of anticoagulation (43% in 219 patients at risk). Even more interestingly, these studies provide data on additional points that are important for the interpretation of mainly morphological data.…”