EASL postgraduate course report: Vascular biology in chronic liver disease and clinical management implications

This article reviews the content of the EASL Congress 2024 postgraduate course on vascular biology in chronic liver disease and its clinical management. It focuses on haemostasis in patients with cirrhosis, vascular liver diseases including porto-sinusoidal vascular disorder and portal vein thrombosis, and portal hypertension and its extrahepatic complications in cirrhosis. Haemostatic changes in cirrhosis coincide with complex shifts between the risks of bleeding and thrombosis, making management decisions challenging. Importantly, laboratory test abnormalities should not be routinely corrected to avoid bleeding. Regarding vascular liver diseases, the term porto-sinusoidal vascular disorder is a recently redefined entity encompassing various overlapping histological patterns (e.g. nodular regenerative hyperplasia, obliterative portal venopathy) and clinical entities (e.g. idiopathic portal hypertension). These disorders have in common the absence of cirrhosis together with vascular alterations in the porto-sinusoidal region and/or feature(s) of portal hypertension. The management of portal vein thrombosis varies according to the presence or absence of cirrhosis. Anticoagulation is increasingly used in this setting and portal vein recanalisation using interventional radiology techniques is an attractive approach. Paradigms on cirrhosis-associated portal hypertension have evolved in recent years: prevention of decompensation in compensated patients has become a prime objective, non-invasive identification of patients with clinically significant portal hypertension has become possible, the concept of "recompensation" in decompensated patients has been proposed, and indications for TIPS (transjugular intrahepatic portosystemic shunts) have been progressively expanded. Extrahepatic vascular complications of cirrhosis include portopulmonary hypertension, hepatopulmonary syndrome, hepatorenal syndrome, and cirrhotic cardiomyopathy. Each of these complications poses unique challenges that affect liver disease management and transplant eligibility, underscoring the need for specialised care.