Related Experiment Videos
Portal vein thrombosis in cirrhosis with variceal hemorrhage
M J Orloff1, M S Orloff, S L Orloff
1Department of Surgery, University of California, San Diego, Medical Center, San Diego, CA 92103-8999, USA.
Insights
Portal vein thrombosis (PVT) in cirrhosis patients undergoing portacaval shunt (PCS) can be successfully treated with phlebothrombectomy. This restores portal blood flow and achieves outcomes comparable to patients without PVT, including similar survival and quality of life.
Area of Science:
- Hepatology
- Vascular Surgery
- Gastroenterology
Background:
- Portal vein thrombosis (PVT) is a complication in patients with cirrhosis and variceal hemorrhage.
- Direct portacaval shunt (PCS) is a treatment option for these patients.
- The presence of PVT may impact PCS outcomes.
Purpose of the Study:
- To evaluate the feasibility and outcomes of direct portacaval shunt (PCS) in patients with cirrhosis and concomitant portal vein thrombosis (PVT).
- To compare the results of PCS in patients with PVT versus those without PVT.
Main Methods:
- Retrospective analysis of 1300 patients with cirrhosis and variceal hemorrhage undergoing direct PCS.
- PVT was present in 85 patients (6.5%) and treated with phlebothrombectomy and balloon catheter extraction.
- Comparison of outcomes between patients with and without PVT, including bleeding recurrence, survival, quality of life, and shunt patency.
Main Results:
- Phlebothrombectomy successfully restored portal blood flow in all 85 patients with PVT.
- Patients with PVT had more advanced liver disease preoperatively.
- PCS in PVT patients effectively reduced portal pressure, stopped variceal bleeding, and achieved long-term patency.
- Survival rates and quality of life were similar between patients with and without PVT after PCS.
Conclusions:
- Portal vein thrombus can be effectively removed in most patients with cirrhosis and variceal hemorrhage.
- Direct portacaval shunt (PCS) provides comparable outcomes in patients with and without PVT.
- Phlebothrombectomy followed by PCS is a viable treatment strategy for patients with PVT and variceal bleeding.
Abstract:
Organized thrombus in the main trunk of the portal vein was encountered in 85 (6.5%) of 1300 patients with cirrhosis and variceal hemorrhage who underwent direct portacaval shunt (PCS). The thrombus was successfully removed with restoration of portal blood flow in all patients by phlebothrombectomy and balloon catheter extraction. Of the 85 patients, 65 were among 400 unselected patients who underwent emergency PCS (16%), and 20 were among 900 selected patients who underwent elective PCS (2%). All patients were closely followed for at least 5 years. Patients with portal vein thrombosis (PVT) had more advanced liver disease than those without PVT, reflected preoperatively in significantly higher (P < 0.01) incidences of ascites (75%), severe muscle wasting (52%), varices of very large size (94%), the hyperdynamic state (94%), severe hypersplenism with a platelet count of less than 50,000/mm3 (92%), and placement in Child's class C (52%). Side-to-side PCS reduced the portal vein-inferior vena cava pressure gradient to a mean of 23 mm saline solution in patients with PVT, similar to the marked pressure reduction obtained in patients without PVT. PCS promptly stopped variceal bleeding in all patients in the emergency PCS group. Permanent prevention of recurrent variceal bleeding was successful in 95% of patients with PVT and more than 99% of patients without PVT. Survival rates were similar in patients with and without PVT. In patients with PVT, survival rates at 30 days and 1, 5, 10, and 15 years following emergency PCS were 69%, 66%, 65%, 55%, and 51%, respectively, and following elective PCS were 95%, 90%, 70%, 65%, and 60%, respectively. Quality of life was similar in patients with and without PVT. Long-term PCS patency was demonstrated yearly in 93% of patients in the group with PVT and in 99.7% of patients without PVT. Other similarities after 5 years between patients with and without PVT, respectively, were the incidences of recurrent encephalopathy (9% vs. 8%), alcohol abstinence (61% vs. 64%), improved liver function (68% vs. 62% to 75%), and return to work (52% vs. 56% to 64%). It was concluded that in patients with cirrhosis and variceal hemorrhage it is almost always possible to remove portal vein thrombus by means of phlebothrombectomy and then perform a direct PCS with results similar to those achieved in the absence of PVT.