Therapeutic anticoagulation after liver transplantation is not useful among patients with pre‐transplant Yerdel‐grade I/II portal vein thrombosis: A two‐center retrospective study

Abstract

Background Portal vein thrombosis (PVT) is no longer a contraindication for liver transplantation (LT). While therapeutic anticoagulation (tAC) is recommended during the waiting period, there is no evidence for its usefulness in the prevention of PVT recurrence after LT. Objectives The aim of our study was to evaluate the role of tAC post‐LT in the prevention of PVT recurrence. Patients/methods All adult LTs performed in two high‐volume centers between 2003 and 2018 were retrospectively analysed. Only patients with PVT classified as Yerdel grade I or II and with standard portal reconstruction were included. PVT recurrence and tAC‐associated morbidity within 1 year were compared between patients receiving tAC or not. Results During the study period, of 2612 LTs performed, 235 (9%) patients with PVT were included; 113 patients (48.1%) received post‐LT tAC (tAC group) while 122 (51.9%) did not (non‐tAC group). The incidence of bleeding events was significantly higher in the tAC group (26 [23%] vs. 5 [4.1%], P < .01) and the initial hospitalization duration was longer (21 vs. 17.5 days, P < .01). Within the first year, PVT recurrence was observed for 9 (3.8%) patients without any difference between the tAC and non‐tAC groups (6 [5.1%] vs. 3 [2.5%], P = .39). The only identified risk factor for PVT recurrence was the recipients’ age (odds ratio= 0.94, P = .03). Graft (P = .11) and patient (P = .44) survival were similar between the two groups. Conclusion Therapeutic anticoagulation is not necessary in the prevention of grade I/II PVT recurrence and is associated with higher morbidity and longer hospital stay.

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

“…Bos et al. found a significant increase in bleeding complications (23% vs. 4.1%, p < .01) and increased length of stay (21 vs. 17.5 days, p < .01) among recipients who received anticoagulation 35 . Sanchez‐Ocana et al.…”

“…Research with regard to prevention of early and late thrombotic complications post LT has mainly focused on the use of aspirin, UFH, LMWH, and Vitamin K antagonists or a combination of these 16,17,27,30–33,35,38–40 . The incidence of bleeding associated with each of these agents in LT recipients is described below.…”

“…These were retrospective observational studies conducted in several different patient cohorts. Two studies were conducted in patients with confirmed PVT prior to LT, two in LDLT and the remaining studies were conducted in a general population of LT recipients 16,30,32,33,35,39,40 . Significant differences were observed between studies with regard to the choice of anticoagulant, dosage, timing of therapy initiation, target ranges (ACT or APTT) and duration.…”

“…40 Several studies examined the use of anticoagulation protocols for LT recipients with pre-operative diagnosis of PVT. 33,35,38 A two-center retrospective study on the utility of UFH infusion followed by Vitamin K antagonist (target INR 2-3) for LT recipients with pre-operative Yerdel I and II PVT showed no significant difference in recurrence of PVT between anticoagulation (Yerdel I: 5.3%; Yerdel II: 5.7%) and no anticoagulation (Yerdel I: 2.5%; Yerdel II: 5.5%) groups; however, the incidence of bleeding and length of stay were significantly higher among recipients in the anticoagulation group (see Figure 2). 35,41 In contrast, Sanchez-Ocaña et al used LMWH (1 mg/kg twice a day) followed by Vitamin K antagonist for a minimum of 6 months for all recipients with pre-or intra-operative diagnosis of PVT (Yerdel I-2: 70%;…”

“…In the majority of the studies, intravenous (IV) UFH was initiated soon after the procedure followed by either SQ UFH, LMWH, or Vitamin K antagonist for minimum duration of 3 months or longer. 16,30,32,33,35,39,40 In studies which involved patients treated with Vitamin K antagonist for confirmed PVT, there was considerable variation in bleeding rates. Bos et al found a significant increase in bleeding complications (23% vs. 4.1%, p < .01) and increased length of stay (21 vs. 17.5 days, p < .01) among recipients who received anticoagulation.…”