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Portal thrombosis in cirrhotics. A retrospective analysis
Insights
Portal vein thrombosis in cirrhosis is common, often causing bleeding. Shunt surgery offers the best survival rates and prevents recurrent bleeding, despite some failures.
Area of Science:
- Hepatology
- Vascular Surgery
- Interventional Radiology
Background:
- Portal vein thrombosis (PVT) complicates portal hypertension in cirrhosis.
- PVT incidence in cirrhotic patients treated for portal hypertension was 16.6% (85/512).
- Bleeding from varices was the primary symptom in 70/85 patients, with a mean of four prior episodes.
Purpose of the Study:
- To evaluate the diagnostic and therapeutic challenges of PVT in cirrhotic patients.
- To assess the efficacy of shunt procedures and disobliterative techniques for PVT.
- To determine prognostic factors influencing survival in PVT patients.
Main Methods:
- Retrospective analysis of 512 cirrhotic patients treated for portal hypertension between 1967-1983.
- Inclusion of angiographic studies and intraoperative evaluation for anatomical assessment.
- Follow-up of 53 patients for up to 5 years, comparing shunt vs. non-shunt procedures.
Main Results:
- Massive portosplenomesenteric involvement occurred in 22.3% (19/85) of PVT patients.
- Disobliterative techniques prior to shunting improved patency and reduced lethal bleeding recurrence by 50%.
- 5-year survival was 51.2% for 39 shunted patients versus <10% for non-shunted patients.
Conclusions:
- Shunt surgery is the most effective treatment for PVT in cirrhosis, preventing life-threatening bleeding.
- Non-shunt procedures and extensive PVT are associated with poor prognosis.
- Disobliterative techniques enhance shunt patency and reduce bleeding recurrence, making shunting the primary therapeutic option.
Abstract:
The development of thrombotic obstruction in the portal bed of cirrhotic patients presents special problems in diagnosis and treatment. In the cirrhotic population treated for portal hypertension at our Surgical Department during the period 1967-1983 (512 patients), the incidence of thrombosis in the portal bed was 16.6% (85 patients). Bleeding was the main presenting symptom (70/85), with a mean of four episodes prior to treatment. Careful angiographic studies and intraoperative evaluation are fundamental steps to determine the exact anatomical involvement, the presence of recanalized veins or fresh occluding clots, and the applicability of shunt procedures. A massive portosplenomesenteric involvement often associated with poor surgical possibilities was found in 19 patients (22.3%). The presence of partially recanalized veins and fresh occluding clot suitable for disobliterative techniques prior to shunt was found in 16 patients, and out of 73 operated patients a total of 55 shunt procedures could be performed. Fifty-three patients who bled from varices could be followed up to 5 years: 39 underwent a shunt procedure with a 51.2% 5-year survival rate, while only one of 14 nonshunted or nonoperated survived up to 3 years, and a lethal bleeding was the cause of death in all but one. Disobliterative techniques (Fogarty thrombectomy and endovenectomy of intimal fibrotic thickenings) prior to shunting provided a good long-term patency rate with a 50% protection from lethal bleeding recurrences. Nonshunt procedures and the extensive involvement of the portal bed are associated with bad prognosis. Also, endoscopic sclerotherapy, attempted in patients with massive thrombosis, could not prevent recurrences and death from bleeding. Despite a 30% failure rate in our study, shunting surgery should be considered the only therapeutical possibility of preventing further thrombotic recurrences and consequent life threatening bleeding episodes.