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Talerico R, Pellegrino S, Plessier A, Ponziani FR, Porfidia A, Landi F, Gasbarrini A, Pola R, Santopaolo F. Safety of Anticoagulant Treatment in Patients With Splanchnic Vein Thrombosis and History of Portal Hypertension-Related Bleeding. Liver Int 2025; 45:e70114. [PMID: 40298453 PMCID: PMC12039759 DOI: 10.1111/liv.70114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2025] [Revised: 03/13/2025] [Accepted: 04/18/2025] [Indexed: 04/30/2025]
Abstract
Splanchnic vein thrombosis (SVT) can be associated with liver cirrhosis or prothrombotic conditions, including myeloproliferative disorders, intra-abdominal inflammation, solid cancers or surgery. While anticoagulation therapy improves outcomes in noncirrhotic patients and reduces all-cause mortality in cirrhotic populations, its safety in patients with a history of portal hypertension (PH)-related bleeding is less clear. This systematic review examines the impact of anticoagulant therapy on rebleeding risk in SVT patients with a history of PH-related bleeding. A systematic review and meta-analysis were conducted according to PRISMA guidelines. A comprehensive search of PubMed, Web of Science and Scopus was performed for studies published up to September 2024. Studies were included if they compared SVT patients with a history of PH-related bleeding receiving anticoagulant therapy versus those not receiving anticoagulants. The primary outcome was the cumulative incidence of PH-related rebleedings. Of 2853 identified studies, five (186 participants) met the inclusion criteria: two randomised controlled trials (RCTs) and three observational studies. The cumulative incidence of PH-related rebleeding was significantly lower in the anticoagulant group at 17.10% [95% CI 17.02, 17.19] compared to the control group at 40.00% [95% CI 39.90, 40.09]. The overall odds ratio (OR) from observational studies was 0.15 [95% CI 0.04, 0.52], indicating a reduced bleeding risk, while the OR from RCTs was 0.84 [95% CI 0.31, 2.32], showing a nonsignificant trend. Anticoagulant therapy may reduce rebleeding risk in SVT patients with a history of PH-related bleeding, but further high-quality studies are needed.
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Affiliation(s)
- Rosa Talerico
- Department of Aging, Orthopedic, and Rheumatologic SciencesFondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro CuoreRomeItaly
| | - Simona Pellegrino
- Department of Aging, Orthopedic, and Rheumatologic SciencesFondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro CuoreRomeItaly
| | - Aurélie Plessier
- Université de Paris, AP‐HP, C, DMU DIGEST, Centre de Référence Des Maladies Vasculaires du Foie, FILFOIE, ERN RARE‐LIVE. Centre de Recherche Sur L'inflammation, InsermParisFrance
| | - Francesca Romana Ponziani
- Department of Medical and Surgical SciencesFondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro CuoreRomeItaly
| | - Angelo Porfidia
- Department of Aging, Orthopedic, and Rheumatologic SciencesFondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro CuoreRomeItaly
| | - Francesco Landi
- Department of Aging, Orthopedic, and Rheumatologic SciencesFondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro CuoreRomeItaly
| | - Antonio Gasbarrini
- Department of Medical and Surgical SciencesFondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro CuoreRomeItaly
| | - Roberto Pola
- Department of Aging, Orthopedic, and Rheumatologic SciencesFondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro CuoreRomeItaly
| | - Francesco Santopaolo
- Department of Medical and Surgical SciencesFondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro CuoreRomeItaly
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Cardi S, Wolf S, Fumagalli RM, Lodigiani C, Rössler F, Trinchero A, Valerio L, Ageno W, Kucher N, Barco S. Splanchnic vein thrombosis (2003-2022): a Swiss nationwide epidemiological study. Thromb Res 2025; 250:109319. [PMID: 40279910 DOI: 10.1016/j.thromres.2025.109319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2025] [Revised: 04/01/2025] [Accepted: 04/08/2025] [Indexed: 04/29/2025]
Abstract
BACKGROUND Splanchnic vein thrombosis (SVT) is a rare form of venous thromboembolism with limited epidemiological data. This study aims to provide a detailed overview in Switzerland using administrative records. METHODS We analysed nationwide patient-level data on SVT-related hospitalizations, including portal, splenic, and hepatic (Budd-Chiari syndrome) vein thrombosis from 2003 to 2022. We assessed trends in crude and age-standardized incidence rates, proportion of SVT-related hospitalizations, readmission rates as well as gender differences, comorbidities, clinical features, and in-hospital outcomes. Multivariable logistic regression was used to identify predictors of in-hospital death. RESULTS SVT was recorded in 17,966 hospitalizations (35 % women) involving 13,689 patients. Portal vein thrombosis was the most frequent manifestation, followed by splenic, hepatic and multisegmental thrombosis. Age-standardized incidence rate increased from 0.4 (95 % CI: 0.3-0.4) per 10,000 general population in 2003 to 1.5 (95 % CI: 1.4-1.6) in 2022, with rising proportions of SVT-related hospitalizations and readmission rates. Case fatality rate remained steady at 13 % and was highest for portal vein thrombosis. For most SVT subtypes, incidence rate was higher in males and case fatality rate in females. Predictors of in-hospital death included liver failure, intestinal infectious diseases, cancer. Common comorbidities included non-neoplastic abdominal diseases (14,010; 78 %), cardiovascular diseases (11,214; 62 %), and cancer (8510; 47 %). Diagnostic or therapeutic procedures involved 56 % of cases, intensive care stay 19 %, and median length of stay was 11 days (Q1-Q3 5-19). CONCLUSION Despite its rarity, SVT is characterized by substantial morbidity and in-hospital mortality. Further research is needed to validate these findings and improve patient management.
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Affiliation(s)
- Silvia Cardi
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Simon Wolf
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland.
| | - Riccardo M Fumagalli
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland
| | - Corrado Lodigiani
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Center for Thrombosis and Hemorrhagic Diseases, Humanitas Clinical and Research Hospital, Rozzano, Milano, Italy
| | - Fabian Rössler
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Alice Trinchero
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Department of Cardiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Walter Ageno
- Department of Medicine, Ospedale Regionale di Bellinzona, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Nils Kucher
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland; University of Zurich, Zurich, Switzerland; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
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Barnum KJ, Patell R, Berry J, Bauer KA. Splanchnic vein thrombosis: management for the thrombosis specialist. J Thromb Haemost 2025; 23:404-416. [PMID: 39442623 DOI: 10.1016/j.jtha.2024.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 10/01/2024] [Accepted: 10/11/2024] [Indexed: 10/25/2024]
Abstract
Splanchnic vein thrombosis (SpVT) is an uncommon site of venous thrombosis that is associated with complications including portal hypertension and hepatic dysfunction. The evaluation and management of this patient population has evolved in recent years, but there are limited data from clinical trials to guide management. Given the various acquired and biologic risk factors leading to the development of SpVT and the potential complications that can arise from it, input from a multidisciplinary team can be valuable in managing such patients, including thrombosis specialists or hematologists, gastroenterologists or hepatologists, interventional radiologists, and surgeons. In this article, we present 4 cases that highlight important issues and considerations in the evaluation of SpVT, including initial diagnostic approach in a patient with a new diagnosis of SpVT, considerations for anticoagulant therapy, management of SpVT in patients with myeloproliferative neoplasms, and the role of interventional vascular procedures in the management of SpVT. By reviewing the current literature, we address clinically relevant questions that are posed to clinicians managing patients with SpVT; we also point out gaps in our current knowledge that merit future investigation.
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Affiliation(s)
- Kevin J Barnum
- Division of Hematology and Hematologic Malignancies, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rushad Patell
- Division of Hematology and Hematologic Malignancies, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/rushadpatell
| | - Jonathan Berry
- Division of Hematology and Hematologic Malignancies, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth A Bauer
- Division of Hematology and Hematologic Malignancies, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.
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Reda S, Chang J, Busse J, Schwarz N, McRae HL, Müller J, Strassburg CP, Oldenburg J, Pötzsch B, Jansen C, Rühl H. Assessment of Hypercoagulability in Splanchnic Vein Thrombosis by Measurement of the Hemostasis Enzymes Thrombin and Activated Protein C. Int J Mol Sci 2024; 26:292. [PMID: 39796151 PMCID: PMC11719462 DOI: 10.3390/ijms26010292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2024] [Revised: 12/29/2024] [Accepted: 12/30/2024] [Indexed: 01/13/2025] Open
Abstract
Splanchnic vein thrombosis (SVT), which is particularly prevalent in myeloproliferative neoplasms (MPNs), has a multifactorial pathomechanism involving the anticoagulant protein C (PC) pathway. To better characterize the hypercoagulable state in SVT we assessed its key enzymes thrombin and activated PC (APC). The study population included 73 patients with SVT, thereof 36 MPN+, confirmed by bone marrow biopsy, 37 MPN-, and 30 healthy controls. Direct measurement of the active enzyme forms of thrombin and APC in the circulation was achieved by using oligonucleotide-based enzyme capture assays (OECA). Additionally, activation markers of coagulation and fibrinolysis were measured. Plasma levels of free thrombin and APC were higher in the MPN+ than in the MPN- cohort, with 0.49 vs. <0.46 pmol/L (p = 0.0057), respectively, 1.23 vs. 0.58 pmol/L (p = 0.0122), and in healthy controls (vs. <0.46 pmol/L, p = 0.0012; vs. 0.54 pmol/L, p = 0.0035). The indirect activation markers prothrombin fragment 1+2, thrombin-antithrombin complex, and D-dimer did not differ between groups. Receiver operating characteristic analysis suggested that SVT patients with MPN can be better distinguished by APC than by conventional indirect thrombin markers. A potential application of these biomarkers to guide anticoagulant therapy and to investigate the role of the PC pathway in MPN-associated hypercoagulability should be further studied.
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Affiliation(s)
- Sara Reda
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, 53127 Bonn, Germany; (S.R.); (J.B.); (N.S.); (J.O.)
- Department of Transfusion Medicine, University Hospital Cologne, 50937 Cologne, Germany
| | - Johannes Chang
- Department of Internal Medicine I, University Hospital Bonn, 53127 Bonn, Germany (C.P.S.); (C.J.)
| | - Johanna Busse
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, 53127 Bonn, Germany; (S.R.); (J.B.); (N.S.); (J.O.)
| | - Nadine Schwarz
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, 53127 Bonn, Germany; (S.R.); (J.B.); (N.S.); (J.O.)
| | - Hannah L. McRae
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, 53127 Bonn, Germany; (S.R.); (J.B.); (N.S.); (J.O.)
| | - Jens Müller
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, 53127 Bonn, Germany; (S.R.); (J.B.); (N.S.); (J.O.)
| | - Christian P. Strassburg
- Department of Internal Medicine I, University Hospital Bonn, 53127 Bonn, Germany (C.P.S.); (C.J.)
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, 53127 Bonn, Germany; (S.R.); (J.B.); (N.S.); (J.O.)
| | - Bernd Pötzsch
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, 53127 Bonn, Germany; (S.R.); (J.B.); (N.S.); (J.O.)
| | - Christian Jansen
- Department of Internal Medicine I, University Hospital Bonn, 53127 Bonn, Germany (C.P.S.); (C.J.)
| | - Heiko Rühl
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, 53127 Bonn, Germany; (S.R.); (J.B.); (N.S.); (J.O.)
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Kim YH, Kim HJ, Park S, Hwang D, Kim HK, Huh S, Yun WS. Comparing clinical outcomes of vitamin K antagonists vs non-vitamin K antagonists in anticoagulant therapy for mesenteric venous thrombosis. J Vasc Surg Venous Lymphat Disord 2024; 12:101903. [PMID: 38754777 PMCID: PMC11523385 DOI: 10.1016/j.jvsv.2024.101903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 04/04/2024] [Accepted: 04/22/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE Non-vitamin K antagonist oral anticoagulants have shown similar efficacy and lower bleeding rates than vitamin K antagonists for venous thromboembolism. However, this has not been proven in mesenteric vein thrombosis. This study aimed to compare the clinical outcomes of vitamin K antagonists and non-vitamin K antagonist oral anticoagulants. METHODS Between January 2014 and July 2022, mesenteric vein thrombosis was diagnosed on computed tomography in 225 patients in a tertiary hospital. Among them, a total of 44 patients who underwent long-term anticoagulation therapy over 3 months were enrolled in this study. Patients were divided into two groups based on the anticoagulant used: vitamin K antagonists (Group 1, n = 21) and non-vitamin K antagonist oral anticoagulants (Group 2, n = 23). The efficacy outcomes were symptom recurrence and thrombus resolution on follow-up computed tomography, and the safety outcome was bleeding complications. RESULTS The median age of the patients was 56 years (range, 46-68 years), and 52% were men. The most common risk factors were unprovoked intra-abdominal infections (30%). The median duration of anticoagulation therapy was 13 months (20 months in Group 1 vs 6 months in Group 2; P = .076). Of the 44 patients, 17 (39%) received the standard treatment. The median follow-up period was longer in Group 1 than in Group 2 (57 vs 28 months; P = .048). No recurrence of mesenteric vein thrombosis-related symptoms were observed in either group. The median duration of follow-up computed tomography was 31 months (42 months in Group 1 vs 18 months in Group 2; P = .064). Computed tomography revealed complete thrombus resolution, partial resolution, and no changes in 71%, 19%, and 10%, respectively (P = .075). Regarding bleeding complications, varix bleeding and melena developed in two patients in Group 2, and anticoagulation treatment thereafter ceased. CONCLUSIONS Despite the short follow-up duration in the non-vitamin K antagonist oral anticoagulants group, there was no clinically significant difference in the thrombus resolution rate or bleeding complications when compared with the vitamin K antagonists group. Although research on the long-term effects of non-vitamin K antagonist oral anticoagulants in patients is limited, non-vitamin K antagonist oral anticoagulants can be considered an alternative to conventional treatments.
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Affiliation(s)
- Young-Hye Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Hyeon Ju Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Hospital, Daegu, South Korea
| | - Suehyun Park
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Chilgok Hospital, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Deokbi Hwang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Hospital, Daegu, South Korea
| | - Hyung-Kee Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Chilgok Hospital, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Seung Huh
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Hospital, Daegu, South Korea
| | - Woo-Sung Yun
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Hospital, Daegu, South Korea.
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Custo S, Tabone E, Aquilina A, Gatt A, Riva N. Splanchnic Vein Thrombosis: The State-of-the-Art on Anticoagulant Treatment. Hamostaseologie 2024; 44:242-254. [PMID: 38354834 DOI: 10.1055/a-2232-5480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
Splanchnic vein thrombosis (SVT) is a rare type of venous thromboembolism occurring within the splanchnic venous system. Portal vein thrombosis is the most common presentation, while Budd-Chiari syndrome is the least common. Liver cirrhosis and abdominal solid cancer are the main local risk factors for SVT, whereas myeloproliferative neoplasms are the predominant systemic risk factors. Signs and symptoms of SVT are nonspecific and include abdominal pain, gastrointestinal bleeding, and ascites. Asymptomatic SVT is not uncommon, and the majority would be detected incidentally on routine abdominal imaging performed for the follow-up of liver diseases and tumors. The management of SVT aims to prevent thrombus progression, promote vessel recanalization, and prevent recurrent venous thromboembolism. Anticoagulation should be started early in order to increase the chances of vessel recanalization and reduce the risk of portal hypertension-related complications. Direct oral anticoagulants have been included in recent guidelines, as alternatives to vitamin K antagonists, after clinical stability has been reached; however, caution is required in patients with liver or kidney dysfunction. Treatment duration is based on the presence (or absence) and type (transient vs. permanent) of risk factors. This narrative review aims to summarize the latest evidence on SVT, with a particular focus on the anticoagulant treatment in special categories of patients (e.g., liver cirrhosis, solid cancer, myeloproliferative neoplasms, pancreatitis, incidentally detected SVT, Budd-Chiari syndrome, and chronic SVT).
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Affiliation(s)
- Scott Custo
- Medical School, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Emma Tabone
- Medical School, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Alexia Aquilina
- Medical School, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
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Okada I, Hagiwara M, Yoneyama H, Kohara S, Shoji Y. Recanalization of port-superior mesenteric vein thrombosis with long-term anticoagulant therapy after failed early anticoagulant therapy. Surg Case Rep 2024; 10:154. [PMID: 38900377 PMCID: PMC11189877 DOI: 10.1186/s40792-024-01948-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 06/11/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Anticoagulant therapy with heparin is the first-line treatment for acute mesenteric vein thrombosis and is effective in improving outcomes. Conversely, patients with failed early anticoagulant therapy occasionally develop bowel infarction requiring surgery. The efficacy of long-term anticoagulant therapy on recanalizing mesenteric vein thrombosis in patients with failed early anticoagulant therapy remains unclear. Herein, we report a patient who achieved recanalization of port-superior mesenteric vein thrombosis treated with anticoagulant therapy for 10 years after failed early anticoagulant therapy, followed by bowel resection. CASE PRESENTATION A 38-year-old male patient visited an outpatient clinic due to acute exacerbation of abdominal pain that had persisted for a month. He was diagnosed with port-superior mesenteric vein thrombosis on contrast-enhanced computed tomography (CT) scan and was transferred to our institution. Although he presented with abdominal pain, his respiration and circulation were stable upon hospital arrival. Anticoagulant therapy with heparin was started, and the patient was admitted to the intensive care unit. However, the patient's abdominal pain worsened, and he began to develop signs of peritonitis. Repeat CT scan revealed bowel infarction. Thus, the patient underwent bowel resection 6 h after admission. The initial surgery was completed with open abdomen management. Bowel anastomosis was performed on the second-look surgery on the first postoperative day. Finally, the abdomen was closed on the third postoperative day after confirming the absence of bowel ischemia progression. The patient had prolonged impaired bowel function with paralytic ileus, but was discharged on the 60th postoperative day. He was then diagnosed with protein C and S deficiency based on the tests performed. Anticoagulant therapy with warfarin was initiated. He also received anticoagulant therapy in the outpatient setting. The patient's port-superior mesenteric vein thrombosis had improved gradually with warfarin during the follow-up period. At 10 years after surgery, total occlusion of the port-superior mesenteric vein was recanalized with improvement of the portal collateral vessels. In addition, no gastric or esophageal varices were observed. CONCLUSIONS Long-term anticoagulation therapy could affect the recanalization of extensive thrombus in multiple segments in patients with mesenteric venous thrombosis.
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Affiliation(s)
- Ichiro Okada
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan.
| | - Masahiro Hagiwara
- Department of Surgery, Sapporo Higashi Tokushukai Hospital, 3-1, North-33, East-14, Higashi-Ku, Sapporo, Hokkaido, 065-0033, Japan
| | - Hisashi Yoneyama
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256, Midoricho, Tachikawa, Tokyo, 190-0014, Japan
| | - Saeko Kohara
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256, Midoricho, Tachikawa, Tokyo, 190-0014, Japan
| | - Yokobori Shoji
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
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Li Q, Wang R, Qi X. Systemic Thrombolysis for Isolated Splenic Vein Thrombosis Secondary to Oral Contraceptives: A Case Report. Int J Womens Health 2024; 16:811-818. [PMID: 38765206 PMCID: PMC11100964 DOI: 10.2147/ijwh.s462610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/09/2024] [Indexed: 05/21/2024] Open
Abstract
Isolated splenic vein thrombosis (ISVT) is a very rare venous thromboembolism in the absence of pancreatic diseases, which can cause acute abdominal pain and chronic left-side portal hypertension. Herein, we reported a 40-year-old female patient who developed ISVT after taking oral contraceptives. Anticoagulation with oral rivaroxaban was the first-line choice of therapy in this case. Since then, abdominal pain alleviated, but she did not achieve vessel recanalization. Thus, a 7-day systemic thrombolysis with urokinase was given. Abdominal pain disappeared, but ISVT was not significantly improved. During follow-up period, long-term anticoagulation with oral rivaroxaban was given. Collectively, this case indicates the possibility of oral contraceptives as a risk factor of ISVT as well as anticoagulation combined with systemic thrombolysis as a choice of treatment for ISVT. Certainly, long-term follow-up is necessary in this case.
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Affiliation(s)
- Qianqian Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, People’s Republic of China
| | - Ran Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, People’s Republic of China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, People’s Republic of China
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Samanta J, Dhar J, Gupta P, Kochhar R. Venous Thrombosis in Acute Pancreatitis: What to and Not to Do? Dig Dis Sci 2024; 69:1537-1550. [PMID: 38600412 DOI: 10.1007/s10620-024-08418-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 03/26/2024] [Indexed: 04/12/2024]
Abstract
Acute pancreatitis is an acute inflammatory condition of the pancreas that has not only local but systemic effects as well. Venous thrombosis is one such complication which can give rise to thrombosis of the peripheral vasculature in the form of deep vein thrombosis, pulmonary embolism, and splanchnic vein thrombosis. The prevalence of these complications increases with the severity of the disease and adds to the adverse outcomes profile. With better imaging and awareness, more cases are being detected, although many at times it can be an incidental finding. However, it remains understudied and strangely, most of the guidelines on the management of acute pancreatitis are silent on this aspect. This review offers an overview of the incidence, pathophysiology, symptomatology, diagnostic work-up, and management of venous thrombosis that develops in AP.
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Affiliation(s)
- Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical College and Research, Chandigarh, India
| | - Jahnvi Dhar
- Department of Gastroenterology, Sohana Hospital, Mohali, Punjab, India
| | - Pankaj Gupta
- Department of Radiodiagnosis, Post Graduate Institute of Medical College and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical College and Research, Chandigarh, India.
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Iwasaki H, Uehara H, Fujimoto Y, Hasuda H, Kusumoto E, Hisamatsu Y, Yoshida R, Sakaguchi Y, Kusumoto T. Fatal pulmonary embolism after surgery for small intestinal necrosis caused by idiopathic portal vein thrombosis: a case report. Surg Case Rep 2024; 10:90. [PMID: 38635121 PMCID: PMC11026322 DOI: 10.1186/s40792-024-01900-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/15/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Portal vein thrombosis (PVT) and venous thromboembolism (VTE) both result from partial or complete occlusion of a blood vessel by a blood clot. The prognosis of PVT is generally good; however, PVT with VTE, including pulmonary embolism (PE), has a high mortality rate. We report here a case of PE after surgery for small intestinal necrosis caused by idiopathic PVT. CASE PRESENTATION A 69-year-old female attended our hospital with a chief complaint of upper abdominal discomfort, and was diagnosed with necrosis of the small intestine as a result of unexplained PVT. She underwent partial resection of the small intestine. On the second postoperative day, she suffered from respiratory distress and went into cardiopulmonary arrest. The patient recovered following cardiopulmonary resuscitation, but PE was detected. Extracorporeal veno-arterial cardiopulmonary resuscitation and anticoagulation therapy were initiated immediately and the thrombus was aspirated as much as possible. Two days later, extracorporeal veno-arterial cardiopulmonary resuscitation was withdrawn and anticoagulation therapy was continued. The patient subsequently recovered with no neurological damage and was discharged on day 26 after the above procedure. CONCLUSIONS Idiopathic PVT is often associated with VTE, and a prompt diagnosis and intervention may result in a good prognosis.
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Affiliation(s)
- Hitoshi Iwasaki
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan.
| | - Hideo Uehara
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Yugo Fujimoto
- Department of Cardiology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Hirofumi Hasuda
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Eiji Kusumoto
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Yuichi Hisamatsu
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Rintaro Yoshida
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Yoshihisa Sakaguchi
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Tetsuya Kusumoto
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
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11
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Eltweri AM, Basamh M, Ting YY, Harris M, Garcea G, Kuan LL. A retrospective multicentre clinical study on management of isolated splenic vein thrombosis: risks and benefits of anticoagulation. Langenbecks Arch Surg 2024; 409:116. [PMID: 38592545 PMCID: PMC11003905 DOI: 10.1007/s00423-024-03295-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 03/21/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Isolated splenic vein thrombosis (iSVT) is a common complication of pancreatic disease. Whilst patients remain asymptomatic, there is a risk of sinistral portal hypertension and subsequent bleeding from gastric varices if recanalisation does not occur. There is wide variation of iSVT treatment, even within single centres. We report outcomes of iSVT from tertiary referral hepatobiliary and pancreatic (HPB) units including the impact of anticoagulation on recanalisation rates and subsequent variceal bleeding risk. METHODS A retrospective cohort study including all patients diagnosed with iSVT on contrast-enhanced CT scan abdomen and pelvis between 2011 and 2019 from two institutions. Patients with both SVT and portal vein thrombosis at diagnosis and isolated splenic vein thrombosis secondary to malignancy were excluded. The outcomes of anticoagulation, recanalisation rates, risk of bleeding and progression to portal vein thrombosis were examined using CT scan abdomen and pelvis with contrast. RESULTS Ninety-eight patients with iSVT were included, of which 39 patients received anticoagulation (40%). The most common cause of iSVT was acute pancreatitis n = 88 (90%). The recanalisation rate in the anticoagulation group was 46% vs 15% in patients receiving no anticoagulation (p = 0.0008, OR = 4.7, 95% CI 1.775 to 11.72). Upper abdominal vascular collaterals (demonstrated on CT scan angiography) were significantly less amongst patients who received anticoagulation treatment (p = 0.03, OR = 0.4, 95% CI 0.1736 to 0.9288). The overall rate of upper GI variceal-related bleeding was 3% (n = 3/98) and it was independent of anticoagulation treatment. Two of the patients received therapeutic anticoagulation. CONCLUSION The current data supports that therapeutic anticoagulation is associated with a statistically significant increase in recanalisation rates of the splenic vein, with a subsequent reduction in radiological left-sided portal hypertension. However, all patients had a very low risk of variceal bleeding regardless of anticoagulation. The findings from this retrospective study should merit further investigation in large-scale randomised clinical trials.
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Affiliation(s)
- A M Eltweri
- Hepatobiliary and Pancreatic Surgery Department, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK.
| | - M Basamh
- Hepatobiliary and Pancreatic Surgery Department, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK
| | - Y Y Ting
- Department of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - M Harris
- Department of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - G Garcea
- Hepatobiliary and Pancreatic Surgery Department, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK
| | - L L Kuan
- Department of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
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12
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Mühlberg KS. Diagnosis and Therapy of Visceral Vein Thrombosis: An Update Based on the Revised AWMF S2k Guideline. Hamostaseologie 2024; 44:135-142. [PMID: 37992729 DOI: 10.1055/a-2178-6670] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023] Open
Abstract
Splanchnic or visceral vein thromboses (VVTs) are atypical thrombotic entities and include thrombosis of the portal vein, hepatic veins (Budd-Chiari syndrome), mesenteric veins, and splenic vein. All VVTs have in common high 30-day mortality up to 20% and it seems to be difficult to diagnose VVT early because of their rarity and their wide spectrum of unspecific symptoms. VVTs are often associated with myeloproliferative neoplasia, thrombophilia, and liver cirrhosis. VVT is primarily diagnosed by sonography and/or computed tomography. In contrast to venous thromboembolism, D-dimer testing is neither established nor helpful. Anticoagulation is the first-line therapy in patients with stable circulation and no evidence of organ complications. Anticoagulation improves significantly recanalization rates and stops the progress of thrombosis. Low-molecular-weight heparin, vitamin K antagonists, as well as direct-acting oral anticoagulants are possible anticoagulants, but it is noteworthy to be aware that all recommendations supporting the off-label use of anticoagulants are based on poor evidence and consist predominantly of case series, observational studies, or studies with small case numbers. When choosing a suitable anticoagulation, the individual risk of bleeding and thrombosis must be weighted very carefully. In cases of bleeding, bowel infarction, or other complications, the optimal therapy should be determined on a case-by-case basis by an experienced multidisciplinary team involving a surgeon. Besides anticoagulation, there are therapeutic options including thrombectomy, balloon angioplasty, stenting, transjugular placement of an intrahepatic portosystemic shunt, liver transplantation, and ischemic bowel resection. This article gives an overview of current diagnostic and therapeutic strategies.
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Affiliation(s)
- Katja S Mühlberg
- Department of Angiology, University of Leipzig, Leipzig, Germany
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13
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Shalaby S, Miraglia R, Senzolo M. Transjugular Intrahepatic Portosystemic Shunt in Nonmalignant Noncirrhotic Portal Vein Thrombosis and Portosinusoidal Vascular Disorder. J Clin Med 2024; 13:1412. [PMID: 38592220 PMCID: PMC10931999 DOI: 10.3390/jcm13051412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/19/2024] [Accepted: 02/26/2024] [Indexed: 04/10/2024] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) emerges as a key treatment for portal hypertension (PH) complications. While international guidelines provide clear indications for its use in cirrhosis, empirical knowledge is notably scarcer in non-cirrhotic PH, particularly in nonmalignant noncirrhotic portal vein thrombosis (NNPVT) and in patients with portosinusoidal vascular disorder (PSVD). Patients afflicted by these rare diseases exhibit distinct clinical profiles compared to their cirrhotic counterparts, often characterized by a younger age, predominantly preserved hepatic functionality even in cases of severe PH, and a higher propensity for extensive splanchnic thrombosis, which intricately complicates TIPS placement, posing unique challenges for its creation. The objective of this review is to synthesize existing literature on the effectiveness, safety, specific indications, and clinical outcomes of TIPS in adult patients with NNPVT or PSVD, focusing also on the technical challenges of TIPS insertion in the presence of portal cavernoma.
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Affiliation(s)
- Sarah Shalaby
- Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy;
| | - Roberto Miraglia
- Radiology Service, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), 90127 Palermo, Italy;
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy;
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14
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Cohen O, Caiano LM, Levy-Mendelovich S. Cancer-associated splanchnic vein thrombosis: Clinical implications and management considerations. Thromb Res 2024; 234:75-85. [PMID: 38183815 DOI: 10.1016/j.thromres.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 01/08/2024]
Abstract
Splanchnic vein thrombosis (SVT), a thrombosis which involves the portal, mesenteric, and splenic veins, and the Budd-Chiari syndrome, represents an uncommon type of venous thromboembolism (VTE). Like with deep vein thrombosis of the lower extremities and pulmonary embolism, ample evidence suggests a significant association between SVT and cancer, particularly intra-abdominal solid malignancies (e.g. hepatobiliary and pancreatic cancers) and myeloproliferative neoplasms (MPN). Clinical symptoms of SVT in cancer patients can be ambiguous, and frequently attributed to the primary cancer itself. Alternatively, SVT may be asymptomatic and detected incidentally during cancer staging or follow-up evaluations. SVT can also precede the diagnosis of cancer and has been associated with poorer outcomes in patients with liver or pancreatic cancers. Therefore, an unprovoked SVT warrants a thorough evaluation for an underlying malignancy or MPN. Cancer-associated SVT carries a high risk of VTE extension, recurrence and bleeding. Extended anticoagulant treatment is often required in the absence of a high bleeding risk. Guidelines suggest treatment with either low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs), although available data on the safety and effectiveness of DOACs in these patients is limited. This comprehensive review outlines the epidemiology, pathogenesis, risk factors, and diagnosis of cancer-associated SVT and underscores the importance of comprehensive patient evaluation and evidence-based management.
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Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-Hashomer, Israel; School of Medicine, Tel Aviv University, Israel; Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | - Lucia Maria Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Sarina Levy-Mendelovich
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-Hashomer, Israel; School of Medicine, Tel Aviv University, Israel
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15
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Calcaterra I, Tufano A, Strano F, Rufolo P, Donnarumma S, Palermo V, De Ruberto F, Cimino E, Guerrino C, Conca P, Iannuzzo G, Di Minno M. Efficacy and safety of direct oral anticoagulants in splanchnic vein thrombosis: a pooled analysis of literature studies. J Thromb Haemost 2024; 22:534-544. [PMID: 37926192 DOI: 10.1016/j.jtha.2023.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 10/18/2023] [Accepted: 10/22/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Limited evidence is available on management of splanchnic vein thrombosis (SVT). OBJECTIVES This study aimed to evaluate safety and efficacy of direct oral anticoagulants (DOACs) for SVT treatment. METHODS Studies were systematically searched in the PubMed, Web of Science, and Scopus databases according to PRISMA guidelines. We assessed any recanalization, full recanalization, recurrence, mortality, and major bleeding as outcomes of interest. Results were reported as weighted mean prevalence (WMP) with 95% CI. Subgroup analyses and meta-regressions have been performed to address heterogeneity and adjust for potential confounders. RESULTS We included a total of 16 studies (17 datasets) on 648 patients with SVT treated with DOACs. We found any recanalization in 60.3% (95% CI: 41.8%-76.3%; I2 = 84.9%; P < .001) and full recanalization in 51.7% (95% CI: 36.0%-67.0%; I2 = 87.4%; P < .001). Recurrent venous thromboembolism occurred in 2.8% (95% CI: 1.4%-5.9%; I2 = 0%; P = .787) and death in 3.4% (95% CI: 1.6%-7.3%; I2 = 13.2%; P = .318) of patients. Major bleeding was reported by 5.8% (95% CI: 3.7%-8.9%; I2 = 29.2%; P = .125) of patients. Results were consistent when separately analyzing prospective studies, retrospective studies, studies on cirrhotic patients, and studies enrolling patients with portal vein thrombosis. Meta-regression analyses showed that an increasing age and cancer impacted the rate of recanalization. Cirrhosis was associated with a higher rate of major bleeding and mortality. CONCLUSION The results of the present study, mostly based on observational studies, suggest good safety and efficacy profiles of DOACs in patients with SVT. Randomized studies are needed to corroborate our findings.
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Affiliation(s)
- Ilenia Calcaterra
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Antonella Tufano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Federica Strano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Paola Rufolo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Sofia Donnarumma
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Vincenzina Palermo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Francesca De Ruberto
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Ernesto Cimino
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Cornelia Guerrino
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Paolo Conca
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Gabriella Iannuzzo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Matteo Di Minno
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy.
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16
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Riva N, Ageno W. How to manage splanchnic vein thrombosis in patients with liver disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:281-288. [PMID: 38066910 PMCID: PMC10727061 DOI: 10.1182/hematology.2023000481] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Liver cirrhosis and splanchnic vein thrombosis (SVT) are strictly correlated. Portal vein thrombosis, the most common location of SVT, is frequently diagnosed in liver cirrhosis (pooled incidence 4.6 per 100 patient-years), and liver cirrhosis is a common risk factor for SVT (reported in 24%-28% of SVT patients). In cirrhosis-associated SVT, anticoagulant treatment reduces mortality rates, thrombosis extension, and major bleeding, and increases the rates of recanalization, compared to no treatment. Achieving vessel recanalization improves the prognosis of cirrhotic patients by reducing liver-related complications (such as variceal bleeding, ascites, hepatic encephalopathy). Anticoagulation should be therefore routinely prescribed to cirrhotic patients with acute SVT unless contraindicated by active bleeding associated with hemodynamic impairment or by excessively high bleeding risk. Of note, early treatment is associated with higher probability of achieving vessel recanalization. The standard treatment consists of low-molecular-weight heparin, followed by oral anticoagulants (eg, vitamin K antagonists or direct oral anticoagulants), if not contraindicated by severe liver dysfunction. Cirrhotic patients with SVT should be treated long-term (especially if candidate for liver transplantation) since liver cirrhosis is a persistent risk factor for recurrent thrombosis. In this review, we discuss the management of SVT in patients with liver cirrhosis, with a focus on the anticoagulant treatment in terms of indications, timing, drugs, duration, and particular scenarios, such as gastroesophageal varices and thrombocytopenia.
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Affiliation(s)
- Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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17
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Muscat-Baron L, Borg AL, Attard LM, Gatt A, Riva N. Cancer-Associated Abdominal Vein Thrombosis. Cancers (Basel) 2023; 15:5293. [PMID: 37958466 PMCID: PMC10649304 DOI: 10.3390/cancers15215293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 10/27/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
Cancer is associated with an increased risk of developing venous thromboembolism, due to its direct influence on the three pillars of Virchow's triad (e.g., compression on the blood vessels by the tumour, blood vessels invasion, and cytokine release), together with the effect of exogenous factors (such as chemotherapy, radiotherapy, surgery). In cancer patients, the risk of thrombosis at unusual sites, such as splanchnic, ovarian and renal vein thrombosis, is also increased. Abdominal vein thromboses are frequently incidental findings on abdominal imaging performed as part of the diagnostic/staging workup or the follow-up care of malignancies. There is little evidence on the management of unusual site venous thromboembolism in cancer patients since there are only a few specific recommendations; thus, the management follows the general principles of the treatment of cancer-associated deep vein thrombosis and pulmonary embolism. This narrative review summarises the latest evidence on cancer-associated abdominal vein thrombosis, i.e., thrombosis of the splanchnic, ovarian and renal veins.
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Affiliation(s)
- Lorna Muscat-Baron
- Medical School, Faculty of Medicine and Surgery, University of Malta, MSD 2080 Msida, Malta; (L.M.-B.); (A.L.B.); (L.M.A.)
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, MSD 2080 Msida, Malta;
| | - Amber Leigh Borg
- Medical School, Faculty of Medicine and Surgery, University of Malta, MSD 2080 Msida, Malta; (L.M.-B.); (A.L.B.); (L.M.A.)
| | - Laura Maria Attard
- Medical School, Faculty of Medicine and Surgery, University of Malta, MSD 2080 Msida, Malta; (L.M.-B.); (A.L.B.); (L.M.A.)
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, MSD 2080 Msida, Malta;
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, MSD 2080 Msida, Malta;
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Gioia S, Riggio O, Nardelli S, Ridola L, Marzano C. Clinical outcomes and prognostic factors in non-cirrhotic non-neoplastic patients with portal vein thrombosis: A single-centre experience. Dig Liver Dis 2023; 55:1487-1495. [PMID: 37230857 DOI: 10.1016/j.dld.2023.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/03/2023] [Accepted: 05/10/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION The knowledge of natural history and prognostic factors of portal vein thrombosis (PVT) is still based on a limited number of studies. AIM To describe our single-center experience with 79 consecutive non-neoplastic non-cirrhotic patients with PVT (15 recent/64 chronic PVT). RESULTS Among patients with recent PVT, 7 received anticoagulation alone, 4 systemic thrombolysis, 3 direct thrombolysis through a TIPS and 1 TIPS alone. Portal recanalization was achieved in 11 patients. In patients with chronic PVT, the rate of variceal progression was high (20% at one year and 50% at two years). The thrombotic involvement of splenic and superior mesenteric veins was the only risk factor for variceal enlargement. The cumulative bleeding rates were 10% at one year and 20% at two years. A multisegmental thrombosis and large varices at entry and a previous variceal bleeding were the independent predictors for variceal bleeding. The cumulative rate of new thrombotic events was 14% at one year and 18% at two years. Eight patients died, 2 because of thrombotic events. There were no bleeding-related deaths. Two-year cumulative survival rate was 90%. CONCLUSIONS Our study supports the importance of anticoagulation especially when a more extended thrombosis is present. Moreover, in patients with chronic PVT, the timing of follow-up endoscopy should be based on the extension of thrombosis and not, as in cirrhosis, on the size of varices at first endoscopy.
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Affiliation(s)
- Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Chiara Marzano
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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Beleva EA. Splanchnic Vein Thrombosis in Myelofibrosis-An Underappreciated Hallmark of Disease Phenotype. Int J Mol Sci 2023; 24:15717. [PMID: 37958701 PMCID: PMC10649007 DOI: 10.3390/ijms242115717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 10/21/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Splanchnic vein thrombosis (SVT) encompasses thrombosis in the vessels of the splanchnic basin and has a relatively rare occurrence with a reported frequency in the general population of 1-2%. An episode of seemingly unprovoked SVT almost always triggers a diagnostic work-up for a Philadelphia chromosome-negative myeloproliferative neoplasm (MPN), since atypical site thrombosis is a hallmark of MPN-associated thrombophilia. Primary myelofibrosis (PMF) is a rare MPN with an estimated incidence between 0.1 and 1/100,000 per year. Although prothrombotic tendency in PMF is not envisioned as a subject of specific therapeutic management, unlike other MPNs, such as polycythemia vera (PV) and essential thrombocythemia (ET), thrombotic risk and SVT prevalence in PMF may be comparably high. Additionally, unlike PV and ET, SVT development in PMF may depend more on procoagulant mechanisms involving endothelium than on blood cell activation. Emerging results from registry data also suggest that PMF patients with SVT may exhibit lower risk and better prognosis, thus highlighting the need for better thrombotic risk stratification and identifying a subset of patients with potential benefit from antithrombotic prophylaxis. This review highlights specific epidemiological, pathogenetic, and clinical features pertinent to SVT in myelofibrosis.
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Affiliation(s)
- Elina A. Beleva
- Clinic of Hematology, Military Medical Academy, 1606 Sofia, Bulgaria;
- QSAR and Molecular Modelling, Institute of Biophysics and Biomedical Engineering, Bulgarian Academy of Sciences, 1113 Sofia, Bulgaria
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20
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Füssel LM, Müller-Wille R, Dinkhauser P, Schauer W, Hofer H. Treatment of colonic varices and gastrointestinal bleeding by recanalization and stenting of splenic-vein-thrombosis: A case report and literature review. World J Gastroenterol 2023; 29:3922-3931. [PMID: 37426315 PMCID: PMC10324528 DOI: 10.3748/wjg.v29.i24.3922] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/27/2023] [Accepted: 05/30/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Splenic vein thrombosis is a known complication of pancreatitis. It can lead to increased blood flow through mesenteric collaterals. This segmental hypertension may result in the development of colonic varices (CV) with a high risk of severe gastrointestinal bleeding. While clear guidelines for treatment are lacking, splenectomy or splenic artery embolization are often used to treat bleeding. Splenic vein stenting has been shown to be a safe option.
CASE SUMMARY A 45-year-old female patient was admitted due to recurrent gastrointestinal bleeding. She was anemic with a hemoglobin of 8.0 g/dL. As a source of bleeding, CV were identified. Computed tomography scans revealed thrombotic occlusion of the splenic vein, presumably as a result of a severe acute pancreatitis 8 years prior. In a selective angiography, a dilated mesenterial collateral leading from the spleen to enlarged vessels in the right colonic flexure and draining into the superior mesenteric vein could be confirmed. The hepatic venous pressure gradient was within normal range. In an interdisciplinary board, transhepatic recanalization of the splenic vein via balloon dilatation and consecutive stenting, as well as coiling of the aberrant veins was discussed and successfully performed. Consecutive evaluation revealed complete regression of CV and splenomegaly as well as normalization of the red blood cell count during follow-up.
CONCLUSION Recanalization and stenting of splenic vein thrombosis might be considered in patients with gastrointestinal bleeding due to CV. However, a multidisciplinary approach with a thorough workup and discussion of individualized therapeutic strategies is crucial in these difficult to treat patients.
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Affiliation(s)
- Lisa-Michaela Füssel
- Department of Internal Medicine I, Gastroenterology and Hepatology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Rene Müller-Wille
- Department of Radiology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Patrick Dinkhauser
- Department of Internal Medicine I, Gastroenterology and Hepatology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Walter Schauer
- Department of Abdominal Surgery, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Harald Hofer
- Department of Internal Medicine I, Gastroenterology and Hepatology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
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Cattaneo D, Bucelli C, Marchetti A, Lionetti M, Fermo E, Bellani V, De Magistris C, Maeda A, Marella A, Primignani M, Consonni D, Gianelli U, Neri A, Baldini L, Bolli N, Iurlo A. Pathological and genomic features of myeloproliferative neoplasms associated with splanchnic vein thrombosis in a single-center cohort. Ann Hematol 2023; 102:1409-1420. [PMID: 37079068 DOI: 10.1007/s00277-023-05217-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/05/2023] [Indexed: 04/21/2023]
Abstract
Here, we reviewed clinical-morphological data and investigated mutational profiles by NGS in a single-center series of 58 consecutive MPN-SVT patients admitted to our hospital between January 1979 and November 2021. We identified 15.5% of PV, 13.8% of ET, 34.5% of PMF, 8.6% of SMF and 27.6% of MPN-U. Most cases (84.5%) carried JAK2V617F mutation, while seven patients were characterized by other molecular markers, namely MPL in four and CALR mutations in three cases. NGS was performed in 54 (93.1%) cases: the most frequent additional mutations were found in TET2 (27.8%) and DNMT3A (16.7%) genes, whereas 25 (46.3%) patients had no additional mutation. Cases with JAK2V617F homozygosity had a higher median number of additional mutations than those with low allele burden. More importantly, all cases of leukemic evolution were characterized by a higher median number of co-mutations, and a co-mutational pattern of high-risk lesions, such as truncating mutations of ASXL1, bi-allelic TP53 loss, and CSMD1 mutations. Nevertheless, no difference was found between cases with and without additional somatic mutations regarding fibrotic progression, SVT recurrence, other thrombo-hemorrhagic complications, or death. After a median follow-up of 7.1 years, ten deaths were recorded; fibrotic progression/leukemic evolution was ascertained in one (1.7%) and six (10.3%) patients, respectively, while 22 (37.9%) patients suffered from recurrent thrombosis. In conclusion, our data underline the importance of using NGS analysis in the management of MPN-related SVT as it can support the MPN diagnosis, particularly in "triple-negative" cases, and provide additional information with potential consequences on prognosis and therapeutic strategies.
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Affiliation(s)
- Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
| | - Cristina Bucelli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Alfredo Marchetti
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Marta Lionetti
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Elisa Fermo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Valentina Bellani
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Claudio De Magistris
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Akihiro Maeda
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Alessio Marella
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Massimo Primignani
- Gastroenterology and Hepatology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Umberto Gianelli
- Division of Pathology, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Antonino Neri
- Scientific Directorate, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Niccolò Bolli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
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Oktaviana J, Lui B, Ho P, Lim HY. A 10-year Australian experience of rare intraabdominal venous thrombosis with comparison to deep vein thrombosis and pulmonary embolism. Blood Coagul Fibrinolysis 2023; 34:191-198. [PMID: 36966765 DOI: 10.1097/mbc.0000000000001213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
Abstract
OBJECTIVE Intra-abdominal venous thromboembolism is rare with heterogeneous management. We aim to evaluate these thrombosis and compare them to deep vein thrombosis and/or pulmonary embolism. METHOD A 10-year retrospective evaluation of consecutive venous thromboembolism presentations (January 2011-December 2020) at Northern Health, Australia, was conducted. A subanalysis of intraabdominal venous thrombosis involving splanchnic, renal and ovarian veins was performed. RESULTS There were 3343 episodes including 113 cases of intraabdominal venous thrombosis (3.4%) - 99 splanchnic vein thrombosis, 10 renal vein thrombosis and 4 ovarian vein thrombosis. Of the splanchnic vein thrombosis presentations, 34 patients (35 cases) had known cirrhosis. Patients with cirrhosis were numerically less likely to be anticoagulated compared to noncirrhotic patients (21/35 vs. 47/64, P = 0.17). Noncirrhotic patients ( n = 64) were more likely to have malignancy compared to those with deep vein thrombosis and/or pulmonary embolism (24/64 vs. 543/3230, P < 0.001), including 10 patients diagnosed at time of splanchnic vein thrombosis presentation. Cirrhotic patients reported more recurrent thrombosis/clot progression (6/34) compared to noncirrhotic patients (3/64) (15.6 vs. 2.3 events/100-person-years; hazard ratio 4.7 (95% confidence interval 1.2-18.9), P = 0.030) and other venous thromboembolism patients (2.6/100-person-years; hazard ratio 4.7, 95% confidence interval 2.1-10.7; P < 0.001) with comparable major bleeding rates. All renal vein thrombosis were provoked including five malignant-related cases while three ovarian vein thrombosis occurred postpartum. No recurrent thrombotic or bleeding complications were reported in renal vein thrombosis and ovarian vein thrombosis. CONCLUSION These rare intraabdominal venous thromboses are often provoked. Splanchnic vein thrombosis (SVT) patients with cirrhosis have a higher rate of thrombotic complications, while SVT without cirrhosis was associated with more malignancy. Given the concurrent comorbidities, careful assessment and individualized anticoagulation decision is needed.
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Affiliation(s)
- Jesica Oktaviana
- Northern Clinical Pathology, Thrombosis and Radiology (NECTAR) Research Group (Northern Pathology Victoria), Department of Haematology, Northern Health, Epping
| | - Brandon Lui
- Northern Clinical Pathology, Thrombosis and Radiology (NECTAR) Research Group (Northern Pathology Victoria), Department of Haematology, Northern Health, Epping
| | - Prahlad Ho
- Northern Clinical Pathology, Thrombosis and Radiology (NECTAR) Research Group (Northern Pathology Victoria), Department of Haematology, Northern Health, Epping
- Australian Centre for Blood Diseases, Monash University, Melbourne
- Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Hui Y Lim
- Northern Clinical Pathology, Thrombosis and Radiology (NECTAR) Research Group (Northern Pathology Victoria), Department of Haematology, Northern Health, Epping
- Australian Centre for Blood Diseases, Monash University, Melbourne
- Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
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Zanetto A, Cossiga V, Shalaby S, Guarino M, Invernizzi F, Lapenna L, Becchetti C, Morisco F, Morelli MC, Merli M, Toniutto P, Burra P. Vascular liver diseases: A sex-oriented analysis of the literature. Dig Liver Dis 2023; 55:178-186. [PMID: 35906168 DOI: 10.1016/j.dld.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 02/01/2023]
Abstract
Vascular liver diseases are an heterogenous group of diseases that collectively represent an important health issue in the field of liver diseases. This narrative review was elaborated by the Special Interest Group (SIG) "Gender in Hepatology" of the Italian Association for the Study of the Liver (AISF). We aimed to review the current knowledge regarding the potential role of biological sex in patients with vascular liver diseases such as splanchnic vein thrombosis, hepatic vein thrombosis, porto-sinusoidal vascular disorder, and hereditary hemorrhagic telangiectasia. As vascular liver diseases commonly affect young individuals, including women in childbearing age, we also included a specific section on the management of pregnancy in these challenging patients.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Valentina Cossiga
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | - Sarah Shalaby
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Maria Guarino
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | - Federica Invernizzi
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Lucia Lapenna
- Department of Translational and Precision Medicine, University of Rome Sapienza, Rome, Italy
| | - Chiara Becchetti
- Hepatology and Gastroenterology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Filomena Morisco
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | | | - Manuela Merli
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Pierluigi Toniutto
- Hepatology and Liver Transplantation Unit, Academic Hospital, University of Udine, Udine, Italy
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy.
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24
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Caiano LM, Riva N, Ageno W. Anticoagulant therapy for splanchnic vein thrombosis: recent updates for patients with liver cirrhosis. Expert Rev Hematol 2023; 16:121-129. [PMID: 36820873 DOI: 10.1080/17474086.2023.2184340] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Liver cirrhosis is accompanied by several hemostatic alterations, which contribute to the current theory of "rebalanced hemostasis." Splanchnic vein thrombosis (SVT) is a frequent complication of liver cirrhosis (17-26% of the cirrhotic patients), and liver cirrhosis is a common risk factor for SVT (24-28% of SVT cases). AREAS COVERED This narrative review aims to describe the current state of the art on the anticoagulant treatment of cirrhotic SVT, with a particular focus on the possible role of the direct oral anticoagulants (DOACs) and recent guidelines on this topic. EXPERT OPINION Early anticoagulant therapy is recommended in cirrhotic patients with acute SVT, to obtain vessel recanalization and decrease the rates of portal hypertension-related complications. Gastroesophageal varices do not represent a contraindication to anticoagulation, if adequate prophylaxis of variceal bleeding is established, and varices band ligation can be safely performed without the need to stop the anticoagulant treatment. The conventional treatment of cirrhotic SVT consisted of low molecular weight heparin, as initial treatment of choice, eventually followed by vitamin K antagonists, but the DOACs can be considered as a reasonable alternative in patients with compensated liver cirrhosis.
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Affiliation(s)
- Lucia M Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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25
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Camerlo S, Ligato J, Rosati G, Carrà G, Russo I, De Gobbi M, Morotti A. Shedding Light on the Pathogenesis of Splanchnic Vein Thrombosis. Int J Mol Sci 2023; 24:ijms24032262. [PMID: 36768584 PMCID: PMC9916478 DOI: 10.3390/ijms24032262] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/15/2023] [Accepted: 01/18/2023] [Indexed: 01/26/2023] Open
Abstract
Splanchnic vein thrombosis is a rare but potentially life-threatening manifestation of venous thromboembolism, with challenging implications both at the pathological and therapeutic level. It is frequently associated with liver cirrhosis, but it could also be provoked by myeloproliferative disorders, cancer of various gastroenterological origin, abdominal infections and thrombophilia. A portion of splanchnic vein thrombosis is still classified as idiopathic. Here, we review the mechanisms of splanchnic vein thrombosis, including new insights on the role of clonal hematopoiesis in idiopathic SVT pathogenesis, with important implications from the therapeutic standpoint.
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Marra P, Dulcetta L, Carbone FS, Muglia R, Muscogiuri G, Cheli M, D’Antiga L, Colledan M, Fagiuoli S, Sironi S. The Role of Imaging in Portal Vein Thrombosis: From the Diagnosis to the Interventional Radiological Management. Diagnostics (Basel) 2022; 12:2628. [PMID: 36359472 PMCID: PMC9689990 DOI: 10.3390/diagnostics12112628] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/26/2022] [Accepted: 10/26/2022] [Indexed: 08/30/2023] Open
Abstract
PURPOSE To illustrate diagnostic and interventional imaging for the characterization and treatment of portal vein thrombosis (PVT). INTRODUCTION The broad spectrum of congenital and acquired PVT manifestations is illustrated, with a focus on the pediatric population; diagnostic and interventional imaging techniques are described. DESCRIPTION PVT frequently presents as an incidental finding at imaging in the screening for liver diseases or for other unrelated reasons. PVT can be classified based on: extension (intrahepatic, extrahepatic, involving the spleno-mesenteric tract, etc.); degree (partial or complete); onset (acute or chronic); and with or without cavernomatous transformation. This comprehensive review relies on the experience gained from a large series of congenital and acquired PVT in a referral center for pediatric and adult liver transplantation. Diagnostic and interventional imaging techniques are described, including: color-Doppler and contrast-enhanced Ultrasound; CT and MR angiography; retrograde portography; percutaneous transhepatic, transplenic, and transmesenteric portography; transjugular intrahepatic portosystemic shunt creation. Pre- and post-operative imaging assessment of the surgical meso-rex bypass is discussed. The description is enriched with an original series of pictorial imaging findings. CONCLUSION PVT is a clinical condition associated with significant morbidity and mortality. Diagnostic and interventional imaging plays a crucial role in both conservative and operative management.
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Affiliation(s)
- Paolo Marra
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Ludovico Dulcetta
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Francesco Saverio Carbone
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Riccardo Muglia
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Giuseppe Muscogiuri
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
- Department of Radiology, IRCCS Istituto Auxologico Italiano, San Luca Hospital, 20149 Milan, Italy
| | - Maurizio Cheli
- Department of Pediatric Surgery, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Lorenzo D’Antiga
- Department of Pediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Michele Colledan
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Stefano Fagiuoli
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
- Department of Gastroenterology, Hepatology and Transplantation Unit, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Sandro Sironi
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
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27
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Zhao JW, Cui XH, Zhao WY, Wang L, Xing L, Jiang XY, Gong X, Yu L. Acute mesenteric ischemia secondary to oral contraceptive-induced portomesenteric and splenic vein thrombosis: A case report. World J Clin Cases 2022; 10:10629-10637. [PMID: 36312508 PMCID: PMC9602218 DOI: 10.12998/wjcc.v10.i29.10629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/21/2022] [Accepted: 09/01/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Mesenteric ischemia represents an uncommon complication of splanchnic vein thrombosis, and it is less infrequently seen in young women using oral contraceptives. Diagnosis is often delayed in the emergency room; thus, surgical intervention may be inevitable and the absence of thrombus regression or collateral circulation may lead to further postoperative ischemia and a fatal outcome. CASE SUMMARY We report a 28-year-old female patient on oral contraceptives who presented with acute abdominal pain. Her physical examination findings were not consistent with her symptoms of severe pain and abdominal distention. These findings and her abnormal blood tests raised suspicion of acute mesenteric ischemia (AMI) induced by splanchnic vein thrombosis. Contrast-enhanced abdominal computed tomography revealed ischemia of the small intestine with portomesenteric and splenic vein thrombosis (PMSVT). We treated the case promptly by anticoagulation after diagnosis. We then performed delayed segmental bowel resection after thrombus regression and established collateral circulation guided by collaboration with a multidisciplinary team. The patient had an uneventful postoperative course and was discharged 14 d after surgery and took rivaroxaban orally for 6 mo. In subsequent follow-up to date, the patient has not complained of any other discomfort. CONCLUSION AMI induced by PMSVT should be considered in young women who are taking oral contraceptives and have acute abdominal pain. Prompt anticoagulation followed by surgery is an effective treatment strategy.
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Affiliation(s)
- Jin-Wei Zhao
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, State Key Laboratory for Zoonotic Diseases, Key Laboratory for Zoonosis Research of The Ministry of Education, Institute of Zoonosis, and College of Veterinary Medicine, Jilin University, Changchun 130000, Jilin Province, China
| | - Xin-Hua Cui
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, State Key Laboratory for Zoonotic Diseases, Key Laboratory for Zoonosis Research of The Ministry of Education, Institute of Zoonosis, and College of Veterinary Medicine, Jilin University, Changchun 130000, Jilin Province, China
| | - Wei-Yi Zhao
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, State Key Laboratory for Zoonotic Diseases, Key Laboratory for Zoonosis Research of The Ministry of Education, Institute of Zoonosis, and College of Veterinary Medicine, Jilin University, Changchun 130000, Jilin Province, China
- Medical College of Yanbian University, Yanbian 133002, Jilin Province, China
| | - Lei Wang
- Department of Imaging Surgery of Second Hospital of Jilin University, Jilin University, Changchun 130000, Jilin Province, China
| | - Lin Xing
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, State Key Laboratory for Zoonotic Diseases, Key Laboratory for Zoonosis Research of The Ministry of Education, Institute of Zoonosis, and College of Veterinary Medicine, Jilin University, Changchun 130000, Jilin Province, China
| | - Xue-Yuan Jiang
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, State Key Laboratory for Zoonotic Diseases, Key Laboratory for Zoonosis Research of The Ministry of Education, Institute of Zoonosis, and College of Veterinary Medicine, Jilin University, Changchun 130000, Jilin Province, China
| | - Xue Gong
- Department of Imaging Surgery of Second Hospital of Jilin University, Jilin University, Changchun 130000, Jilin Province, China
| | - Lu Yu
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, State Key Laboratory for Zoonotic Diseases, Key Laboratory for Zoonosis Research of The Ministry of Education, Institute of Zoonosis, and College of Veterinary Medicine, Jilin University, Changchun 130000, Jilin Province, China
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Messina F, Calabrese G, Tebala C, Turano L, Arcadi N. A simultaneous superior mesenteric arterial and venous thrombosis in an elderly woman with a previous COVID-19 pneumonia: A suggestive case report diagnosed at computed tomography angiography. Radiol Case Rep 2022; 17:2869-2873. [PMID: 35702668 PMCID: PMC9187905 DOI: 10.1016/j.radcr.2022.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/04/2022] [Accepted: 05/11/2022] [Indexed: 11/19/2022] Open
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29
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Tan R, Daneshmand A, Parys S, Watanabe Y, Sieunarine K. Splanchnic venous thrombosis: aetiologies and a review of the literature. ANZ J Surg 2022; 92:2224-2228. [PMID: 35751848 DOI: 10.1111/ans.17863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/12/2022] [Accepted: 06/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Splanchnic vein thrombosis (SVT) is an uncommon yet potentially life-threatening manifestation of venous thromboembolism. The aim of this study was to present a retrospective analysis of a cohort of Western Australian patients diagnosed with SVT on imaging study, and a review of the literature surrounding the aetiology, location, anticoagulation treatment and outcomes of SVT. METHODS All patients diagnosed with SVT over a five-year period from 2015 to 2020 in three tertiary hospitals in Western Australia were identified by using an electronic search engine of imaging reports. Collected data included patient demographics and co-morbidity, presentation data, location of thrombus, aetiology of thrombus, treatment with anti-coagulation, length of stay and outcome data including mortality. RESULTS A total of 164 patients met inclusion criteria. The 90-day mortality was 20.1%; 64% of whom were those with portal vein thrombosis. Aetiology was grouped into haematological conditions (4 patients), non-haematological conditions (130 patients), a combination of factors (17 patients) and idiopathic (13 patients). The majority of deaths were due to malignancy, severe pancreatitis or decompensated liver cirrhosis. CONCLUSION Whilst the prevalence of SVT is rising with the increase in accessibility to radiological studies, it remains a diagnostic and therapeutic challenge for clinicians. With no consensus guidelines available to direct treatment, the management of patients with SVT should be individualized and considered carefully. The potential complications of venous thrombosis, SVT recurrence or extension and the risk of bleeding need to be evaluated before the commencement of anticoagulation therapy.
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Affiliation(s)
- Rebekah Tan
- General Surgery Department, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Ali Daneshmand
- General Surgery Department, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Simon Parys
- General Surgery Department, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Yuki Watanabe
- General Surgery Department, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Kishore Sieunarine
- Department of Vascular Surgery, Hollywood Hospital, Perth, Western Australia, Australia
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30
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AlSheef M, Abuzied Y, Alzahrani GR, AlAraj N, AlAqeel N, Aljishi H, Alomar MJ, Zaidi ARZ, Alarfaj OM. Combined Oral Contraceptives and Vascular Thrombosis: A Single-Center Experience. Cureus 2022; 14:e25865. [PMID: 35836444 PMCID: PMC9275533 DOI: 10.7759/cureus.25865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2022] [Indexed: 11/12/2022] Open
Abstract
Background Combined oral contraceptives (COCs) are frequently prescribed for contraception, to regulate ovulation and treat endometriosis, and to control menopausal symptoms. A major risk of hormonal contraceptives is vascular thrombosis. Methods A retrospective chart review of female patients with deep vein thrombosis (DVT), pulmonary embolism (PE), or other sites of thrombosis or emboli seen in the thrombosis clinic of the department of internal medicine at a tertiary care hospital in Saudi Arabia between March 2010 and February 2015 was performed to identify and characterize which women were taking COCs. Results Of 1,008 patients treated for DVT, PE, or other sites of thrombosis or emboli, 100 (9.9%) were taking COCs. Venous (98%) and arterial (2%) thromboses were seen. Overall, 62% of the patients experienced a DVT and 26% pulmonary emboli, and 20% of the patients experienced unusual sites of thrombosis. Furthermore, 53% were obese or morbidly obese. The incidence of venous thrombosis was the highest during the first year of COC use (73%). Of the patients, 8% had thrombophilia. Conclusion This study characterizes Saudi women with thrombotic events taking COCs and identifies risk factors, including unusual sites of thrombosis. Most patients experienced the vascular event during the first year of taking COCs. Age of 40-50 years, obesity, and thrombophilia were the commonly observed risk factors.
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31
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Anticoagulant therapy for splanchnic vein thrombosis: an individual patient data meta-analysis. Blood Adv 2022; 6:4516-4523. [PMID: 35613465 DOI: 10.1182/bloodadvances.2022007961] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/10/2022] [Indexed: 11/20/2022] Open
Abstract
Robust evidence on the optimal management of splanchnic vein thrombosis (SVT) is lacking. We conducted an individual patient meta-analysis to evaluate the effectiveness and safety of anticoagulation for splanchnic vein thrombosis (SVT). MEDLINE, EMBASE, and clincaltrials.gov., were searched up to June 2021 for prospective cohorts or randomized clinical trials including patients with SVT. Data from individual datasets were merged, and any discrepancy with published data was resolved by contacting study authors. Three studies for a total of 1635 patients were included. Eighty-five percent of patients received anticoagulation for a median duration of 316 days (range 1 to 730 days). Overall, incidence rates for recurrent VTE, major bleeding, and mortality were 5.3/100 patients-years (p-y) (95% CI, 5.1 to 5.5), 4.4/100 p-y (95% CI, 4.2 to 4.6), and 13.0/100 p-y (95% CI, 12.4 to 13.6), respectively. The incidence rates of all outcomes were lower during anticoagulation and higher after treatment discontinuation or when anticoagulation was not administered. In multivariable analysis, anticoagulant treatment appeared to be associated with a lower risk of recurrent VTE (Hazard Ratio [HR] 0.42; 95% CI, 0.27 to 0.64), major bleeding (HR 0.47; 95% CI, 0.30 to 0.74), and mortality (HR 0.23; 95% CI, 0.17 to 0.31). Results were consistent in patients with cirrhosis, solid cancer, myeloproliferative neoplasms, unprovoked SVT, and SVT associated with transient or persistent non-malignant risk factors. In patients with SVT the risk of recurrent VTE and major bleeding is substantial. Anticoagulant treatment is associated with reduced risk of both outcomes.
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Sissingh NJ, Groen JV, Koole D, Klok FA, Boekestijn B, Bollen TL, van Santvoort HC, Verdonk RC, Bonsing BA, van Eijck CHJ, van Hooft JE, Mieog JSD. Therapeutic anticoagulation for splanchnic vein thrombosis in acute pancreatitis: A systematic review and meta-analysis. Pancreatology 2022; 22:235-243. [PMID: 35012902 DOI: 10.1016/j.pan.2021.12.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/19/2021] [Accepted: 12/17/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The optimal management of patients with acute pancreatitis (AP) and splanchnic vein thrombosis (SVT) remains unknown. This systematic review and meta-analysis aimed to see if therapeutic anticoagulation (AC) improves outcomes in patients with AP and SVT. METHODS A systematic review was performed according to PRISMA guidelines. Main outcomes were recanalization, recurrent venous thromboembolism, development of varices, collaterals or cavernoma, haemorrhage and mortality. Meta-analysis were performed with the Mantel-Haenszel random effect models. RESULTS Seven retrospective cohort studies (3495 patients) were included. SVT occurred in 233 (7%) patients and involved most frequently the splenic vein (44%). Therapeutic AC was administered to 109 (47%) patients, most frequently to those with triple vessel thrombosis (72%) and least to those with isolated splenic vein (22%) or superior mesenteric vein thrombosis (0%). Most studies administered (low molecular weight) heparin followed by warfarin (duration ranged between 1.5 and 12 months). This meta-analysis showed an absolute risk difference of 9% (95% confidence interval [CI] = -11-28%) for recanalization, -3% (95% CI = -19-12%) for the development of varices, collaterals or cavernoma, 3% (95% CI = -6-12%) for haemorrhage and 2% (95% CI = -8-12%) for mortality. CONCLUSIONS Based on the currently available data, it remains unclear if therapeutic anticoagulation provides benefit to acute pancreatitis patients with splanchnic vein thrombosis. These results are based on low quality data underlining the need for further higher quality studies.
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Affiliation(s)
- Noor J Sissingh
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands; Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands.
| | - Jesse V Groen
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Dylan Koole
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederikus A Klok
- Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Bas Boekestijn
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, University Medical Center, Utrecht, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
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Gadani S, Partovi S, Levitin A, Zerona N, Sengupta S, D’Amico G, Diago Uso T, Menon KVN, Quintini C. Narrative review of portal vein thrombosis in cirrhosis: pathophysiology, diagnosis, and management from an interventional radiology perspective. Cardiovasc Diagn Ther 2022; 12:135-146. [PMID: 35282661 PMCID: PMC8898691 DOI: 10.21037/cdt-21-98] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 10/25/2021] [Indexed: 09/01/2023]
Abstract
OBJECTIVE This paper examines the incidence, clinical presentation, and pathophysiology of portal vein thrombosis (PVT) in cirrhosis. Additionally, we have reviewed the literature regarding the current status of medical and interventional radiology management of PVT and have proposed a novel algorithm for the management given different clinical scenarios. Lastly two representative cases displaying endovascular treatment options are provided. BACKGROUND Portal vein thrombus in the setting of cirrhosis is an increasingly recognized clinical issue with debate on its pathophysiology, natural course, and optimal treatment. Approximately one-third of patients are asymptomatic, and detection of the thrombus is an incidental finding on imaging performed for other reasons. In 30% to 50% of patients, PVT resolves spontaneously. However, there is increased post-transplant mortality in patients with completely occlusive PVT, therefore effective early revascularization strategies are needed for patients with complete PVT who are expected to undergo liver transplant. Additionally, no consensus has been reached regarding PVT treatment in terms of timing and type of interventions as well as type and duration of anticoagulation. METHODS Computerized literature search as well as discussion with experts in the field. CONCLUSIONS Management of PVT is complex, as many variables affect which treatments can be used. Anticoagulation appears to be the optimal first-line treatment in patients with acute PVT but without bleeding varices or mesenteric ischemia. Minimally invasive treatments include various methods of mechanical thrombectomy, chemical thrombolysis, and transjugular intrahepatic portosystemic shunt (TIPS) placement with or without variceal embolization. Definitive recommendations are difficult due to lack of high quality data and continued research is needed to evaluate the efficacy of different anticoagulants as well as the timing and use of various minimally invasive therapies in specific circumstances.
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Affiliation(s)
- Sameer Gadani
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sasan Partovi
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Abraham Levitin
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nicholas Zerona
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Shreya Sengupta
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Giuseppe D’Amico
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Teresa Diago Uso
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - K. V. Narayanan Menon
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Cristiano Quintini
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Turatti G, Fedeli U, Valerio L, Klok FA, Cohen AT, Hunt BJ, Simioni P, Middeldorp S, Ageno W, Kucher N, Konstantinides SV, Schievano E, Barco S. Splanchnic vein thrombosis-related mortality in the Veneto region (Italy), 2008-2019: Retrospective analysis of epidemiological data. Thromb Res 2021; 209:41-46. [PMID: 34856495 DOI: 10.1016/j.thromres.2021.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/31/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Splanchnic vein thrombosis (SVT) is an uncommon manifestation of venous thromboembolism. Epidemiological data on SVT-related mortality rate is not available to date. METHODS We investigated time trends in SVT-related mortality rate, 2008-2019, in Veneto, an Italian high-income region of approximatively 5,000,000 inhabitants. SVT-related deaths were identified by the following ICD-10 codes: I81 (portal vein thrombosis), K75.1 (phlebitis of portal vein), K76.3 (liver infarction), K76.5 (hepatic veno-occlusive disease) or I82.0 (Budd-Chiari syndrome). RESULTS During the study period, a total of 557,932 deaths were recorded. SVT was reported in 823 cases; 776 (94%) consisted of portal vein thrombosis. The age-standardized SVT-related mortality rate varied from 1.47 (year 2008) to 1.52 (year 2019) per 100,000 person-years. An increase in the cause-specific annual mortality rate was observed in women (0.56 in 2008 to 1.04 per 100,000 person-years in 2019; average annual percent change +5.7%, 95%CI +3.1; +8.3%). In men, the cause-specific mortality rate moved from 2.53 in 2008 to 2.03 per 100,000 person-years in 2019 (average annual percent change -1.2%, 95%CI -4.0; +1.6%). After conditioning for age and sex, the odds of having a concomitant liver disease were higher for SVT-related deaths (OR 31.6; 95%CI 17.1-37.0) compared with non-SVT-related deaths. This also applies to gastrointestinal cancers (OR 1.28; 95%CI 1.07-1.55), although to a lesser extent. CONCLUSIONS We report first epidemiological estimates of SVT-related mortality in a Western country. These values will serve as a reference to weight novel potential factors associated with SVT-related death and interpret them from an epidemiological perspective.
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Affiliation(s)
- Giacomo Turatti
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany; General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Ugo Fedeli
- Epidemiological Department, Azienda Zero, Padova, Veneto Region, Italy
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Frederikus A Klok
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany; Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Alexander T Cohen
- Department of Haematology, Thrombosis & Haemophilia Centre, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Beverley J Hunt
- Thrombosis & Haemophilia Centre, Guys & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Saskia Middeldorp
- Department of Internal Medicine & Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Nils Kucher
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Elena Schievano
- Epidemiological Department, Azienda Zero, Padova, Veneto Region, Italy
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany; Department of Angiology, University Hospital Zurich, Zurich, Switzerland.
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Khayyat YM. Can we use non-invasive parameters to predict the development of gastroesophageal varices in cirrhotic patients with and without portal vein thrombosis? An observational study from the western region of Saudi Arabia. EGYPTIAN LIVER JOURNAL 2021; 11:25. [DOI: 10.1186/s43066-021-00095-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The prevention of portal hypertensive complications, including upper gastrointestinal bleeding, is critically important and achieved only through the use of upper endoscopy for the management of oesophageal gastric varices (EGVs). There is a paucity of data and limited utilization of non-invasive predictive parameters to guide the selection of patients who may benefit from endoscopic surveillance, especially in cirrhotic patients with coexistent portal vein thrombosis.
Results
The study was conducted in eight hospitals in the western region of Saudi Arabia over the period of 2015–2017. Among 1349 chronic liver disease patients, eighty-five patients with complete endoscopic findings were included in the study. Twenty-eight patients were diagnosed with non-malignant PVT. Twenty-five patients (89%) developed oesophageal varices, compared with 57 patients with cirrhosis without PVT. A predictive factor for the development of oesophageal varices of statistical significance was hypoalbuminemia in PVT patients (p=0.04). No statistically significant differences were found in other biochemical markers (p<0.05) between the PVT and non-PVT groups.
Conclusions
The prevalence of oesophageal varices is increased in PVT patients. Serum albumin can be utilized as a predictor of varices development in cirrhosis patients.
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Chandan S, Buddam A, Khan SR, Mohan BP, Ramai D, Bilal M, Dhindsa B, Bhogal N, Kassab LL, Goyal H, Perisetti A, Facciorusso A, Adler DG. Use of therapeutic anticoagulation in splanchnic vein thrombosis associated with acute pancreatitis: a systematic review and meta-analysis. Ann Gastroenterol 2021; 34:862-871. [PMID: 34815653 PMCID: PMC8596205 DOI: 10.20524/aog.2021.0661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/26/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Splanchnic vein thrombosis is a well-recognized local vascular complication of acute pancreatitis (AP), estimated to occur in approximately 15% of patients. While splanchnic vein recanalization occurs spontaneously in approximately one third of patients, severe complications such as bowel ischemia and liver failure have also been reported. At present, there is no consensus on whether patients presenting with AP-associated splanchnic vein thrombosis should receive therapeutic anticoagulation. METHODS We searched multiple databases from inception through December 2020 to collect studies that compared the clinical outcomes of patients with AP and splanchnic vein thrombosis who received therapeutic anticoagulation (AC group) with those who did not (N-AC group). A meta-analysis was performed to calculate the relative risk (RR) of vessel recanalization, bleeding complications, collateral formation and death in the 2 groups. RESULTS Seven studies with 8353 patients, 339 of whom had splanchnic vein thrombosis, were included in the final analysis. A total of 154 patients (45.4%) had acute severe pancreatitis. A significantly higher proportion of patients had vessel recanalization in the AC group: RR 1.6, 95% confidence interval 1.17-2.27; I 2=0%; P=0.004. There was no difference between the 2 groups in the RR of bleeding complications, collateral formation and death. CONCLUSIONS Our analysis demonstrated that, among patients with AP-associated splanchnic vein thrombosis, therapeutic anticoagulation resulted in recanalization of the involved vessels without significantly increasing the risk of bleeding complications. There was no difference in the RR of death or the rates of collateral vessel formation during the follow up.
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Affiliation(s)
- Saurabh Chandan
- Division of Gastroenterology & Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, USA (Saurabh Chandan, Avanija Buddam)
| | - Avanija Buddam
- Division of Gastroenterology & Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, USA (Saurabh Chandan, Avanija Buddam)
| | - Shahab R. Khan
- Department of Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA (Shahab R. Khan)
| | - Babu P. Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA (Babu P. Mohan, Douglas G. Adler)
| | - Daryl Ramai
- Internal Medicine, Brooklyn Hospital Center, Brooklyn, New York, USA (Daryl Ramai)
| | - Mohammad Bilal
- Division of Gastroenterology, University of Minnesota & Minneapolis VA Health Care System, Minneapolis, Minnesota, USA (Mohammad Bilal)
| | - Banreet Dhindsa
- Gastroenterology & Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA (Banreet Dhindsa, Neil Bhogal)
| | - Neil Bhogal
- Gastroenterology & Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA (Banreet Dhindsa, Neil Bhogal)
| | - Lena L. Kassab
- Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA (Lena L. Kassab)
| | - Hemant Goyal
- Gastroenterology, The Wright Center For Graduate Medical Education, Scranton, Philadelphia, USA (Hemant Goyal)
| | - Abhilash Perisetti
- Gastroenterology & Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA (Abhilash Perisetti)
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy (Antonio Facciorusso)
| | - Douglas G. Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA (Babu P. Mohan, Douglas G. Adler)
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Rupoli S, Fiorentini A, Morsia E, Svegliati-Baroni G, Micucci G, Maroni L, Garvey KB, Fiorentini A, Riva A, Da Lio L, Benedetti A, Offidani M, Olivieri A, Giuseppe T. Anticoagulation and Vessel Recanalization in Cirrhotic Patients with Splanchnic Vein Thrombosis: A Multidisciplinary "Real Life" Experience. Vasc Health Risk Manag 2021; 17:619-629. [PMID: 34594107 PMCID: PMC8478488 DOI: 10.2147/vhrm.s310615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/19/2021] [Indexed: 11/23/2022] Open
Abstract
Background and Aim Splanchnic vein thrombosis (SVT) is a potentially life-threatening complication of liver cirrhosis. This study aimed to evaluate the impact of a multi-disciplinary approach and early anticoagulation therapy (AT) on bleeding/thrombotic events, recanalization rates and outcome of cirrhotic patients with SVT. Methods This is a single-center, registry-based cohort study. Over 17 years, 149 SVT patients were enrolled and prospectively evaluated. Regarding cirrhotic-SVT, a pre-specified algorithm, guiding initial posology of AT and follow-up visits schedule, was performed. Major bleeding (MB), thrombotic events, functional liver scores and all cause-mortality were investigated. Efficacy of AT was evaluated by radiological imaging. Results In cirrhotic-SVT, the incidence rate of MB was 8.4 per 100 patient-year (95% CI, 3.83–15.97), while the incidence rate of thrombosis was 5.6 per 100 patient-year (95% CI, 2.05–12.2). In incidental SVT treated with AT, MB incidence was 6.5 per 100 patient-year (95% CI: 2.8–12.82), while in symptomatic SVT was 2.2 per 100 patient-year (95% CI: 0.25–8.02). All thrombotic recurrences occurred in incidental SVT (7.7 per 100 patient-years; 95% CI, 3.71–14.26). Overall survival was significantly higher in patients who had at least a partial recanalization (p < 0.01) and partial/total recanalization was independently associated with improved MELD score at multivariate analysis (HR 2.62, 95% CI 1.1–6.47, p = 0.03). Conclusion In cirrhotic SVT patients, partial or total resolution of thrombosis ameliorates liver function and is associated with higher overall survival. A multidisciplinary approach together with radiological follow-up at pre-fixed time improves patient selection and monitoring.
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Affiliation(s)
- Serena Rupoli
- Clinica Ematologica, Dipartimento di Medicina Interna, Ancona, Italy
| | | | - Erika Morsia
- Clinica Ematologica, Dipartimento di Medicina Interna, Ancona, Italy
| | | | - Giorgia Micucci
- Clinica Ematologica, Dipartimento di Medicina Interna, Ancona, Italy
| | - Luca Maroni
- SOD Clinica di Gastroenterologia, Epatologia ed Endoscopia Digestiva d'Urgenza, Ancona, Italy
| | | | - Alessandro Fiorentini
- SOD Malattie Infettive emergenti e degli immunodepressi, Ospedali Riuniti Ancona, Ancona, Italy
| | - Alessandra Riva
- SOD Clinica Malattie Infettive tropicali, parassitologia, epatiti croniche, Ancona, Italy
| | - Lidia Da Lio
- SOD Medicina di Laboratorio, Ospedali Riuniti Ancona, Ancona, Italy
| | - Antonio Benedetti
- SOD Clinica di Gastroenterologia, Epatologia ed Endoscopia Digestiva d'Urgenza, Ancona, Italy
| | - Massimo Offidani
- Clinica Ematologica, Dipartimento di Medicina Interna, Ancona, Italy
| | - Attilio Olivieri
- Clinica Ematologica, Dipartimento di Medicina Interna, Ancona, Italy
| | - Tarantino Giuseppe
- SOD Clinica di Gastroenterologia, Epatologia ed Endoscopia Digestiva d'Urgenza, Ancona, Italy
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Anticoagulant therapy for splanchnic vein thrombosis: a systematic review and meta-analysis. Blood 2021; 137:1233-1240. [PMID: 32911539 DOI: 10.1182/blood.2020006827] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/24/2020] [Indexed: 12/15/2022] Open
Abstract
Treatment of splanchnic vein thrombosis (SVT) is challenging, and evidence to guide therapeutic decisions remains scarce. The objective of this systematic review and meta-analysis was to determine the efficacy and safety of anticoagulant therapy for SVT. MEDLINE, EMBASE, and clinicaltrials.gov were searched from inception through December 2019, without language restrictions, to include observational studies and randomized controlled trials reporting radiological or clinical outcomes in patients with SVT. Pooled proportions and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated in a random-effects model. Of 4312 records identified by the search, 97 studies including 7969 patients were analyzed. In patients receiving anticoagulation, the rates of SVT recanalization, SVT progression, recurrent venous thromboembolism (VTE), major bleeding, and overall mortality were 58% (95% CI, 51-64), 5% (95% CI, 3-7), 11% (95% CI, 8-15), 9% (95% CI, 7-12), and 11% (95% CI, 9-14), respectively. The corresponding values in patients without anticoagulation were 22% (95% CI, 15-31), 15% (95% CI, 8-27), 14% (95% CI, 9-21), 16% (95% CI, 13-20), and 25% (95% CI, 20-31). Compared with no treatment, anticoagulant therapy obtained higher recanalization (RR, 2.39; 95% CI, 1.66-3.44) and lower thrombosis progression (RR, 0.24; 95% CI, 0.13-0.42), major bleeding (RR, 0.73; 95% CI, 0.58-0.92), and overall mortality (RR, 0.45; 95% CI, 0.33-0.60). These results demonstrate that anticoagulant therapy improves SVT recanalization and reduces the risk of thrombosis progression without increasing major bleeding. The incidence of recurrent VTE remained substantial in patients receiving anticoagulation, as well. Effects were consistent across the different subgroups of patients. This trial was registered on the PROPERO database at (https://www.crd.york.ac.uk/prospero//display_record.php?ID=CRD42019127870) as #CRD42019127870.
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Cohen O, Caiano LM, Tufano A, Ageno W. Cancer-Associated Splanchnic Vein Thrombosis. Semin Thromb Hemost 2021; 47:931-941. [PMID: 34116580 DOI: 10.1055/s-0040-1722607] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Splanchnic vein thrombosis (SVT), which includes portal, mesenteric, and splenic vein thrombosis and the Budd-Chiari syndrome, is an infrequent manifestation of venous thromboembolism (VTE). Like typical site VTE, SVT is also frequently associated with cancer, particularly intra-abdominal solid malignancies and myeloproliferative neoplasms (MPNs). The clinical presentation of SVT is nonspecific. Symptoms may be related to the underlying malignancy, and thrombosis is incidentally diagnosed by imaging studies for cancer staging or follow-up in a substantial proportion of cases. The occurrence of SVT predicts worse prognosis in patients with liver or pancreatic cancer and, not uncommonly, SVT may precede the diagnosis of cancer. Therefore, the occurrence of an apparently unprovoked SVT should prompt careful patient evaluation for the presence of an underlying malignancy or MPN. Cancer patients carry a high risk of VTE extension and recurrence and long-term anticoagulant treatment is suggested in the absence of high risk of bleeding. Either LMWH or direct oral anticoagulants (DOACs) are suggested for the treatment of patients with cancer-related SVT, although limited experience is available on the use of DOACs in these settings. Vitamin K antagonists (VKAs) are suggested for the short and long-term treatment of SVT associated with MPN. This review outlines the epidemiological aspects, pathogenesis, risk factors, and diagnosis of cancer-associated SVT, and addresses questions regarding the management of this challenging condition.
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Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis and the Amalia Biron Research Institute, Sheba Medical Center, Tel-HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Lucia Maria Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Antonella Tufano
- Regional Reference Centre for Coagulation Disorders, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Current Indications and Long-Term Outcomes of Surgical Portosystemic Shunts in Adults. J Gastrointest Surg 2021; 25:1437-1444. [PMID: 32424687 DOI: 10.1007/s11605-020-04643-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/03/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical portosystemic shunts are rare. We reviewed indications, operative details, and outcomes of patients undergoing surgical portosystemic shunt procedures. METHODS We retrospectively reviewed clinical data of consecutive patients between 1997 and 2018 from a single institution. Clinical characteristics and outcomes were compared between two groups: patients with portomesenteric venous thrombosis (PMVT) vs those with cirrhosis. Endpoints included 30-day mortality, shunt-related complications, patency, and survival. RESULTS There were 99 patients, 45 male and 54 female, with a mean age of 46 ± 18 years, enrolled in the study. There were 63 patients (63%) with PMVT and 36 patients (36%) with cirrhosis. Both groups had similar demographics, cardiovascular risk factors, and aneurysm extent, except for more diabetes among those with cirrhosis (p < 0.05). There were no significant differences in procedural metrics and intra-procedure complications between groups, except that patients with PMVT underwent more non-selective shunts than those with cirrhosis (63% vs. 30%, p < 0.001). There were two 30-day deaths (2%), with no difference in mortality and MAEs between groups. On univariate analysis, cholangiopathy and PMVT were associated with graft thrombosis (HR = 9.22, 95% CI 1.22-70.27) while race, smoking, cardiac comorbidity, type of operative shunt, configuration of the shunt, and use of conduit were not (p > 0.05). Patients with PMVT had significantly lower 1-, 5-, and 10-year primary (77%, 71%, and 71% vs. 97%, p = 0.009) and secondary patency (88%, 76%, and 72% vs. 96%, p = 0.027) compared with those with cirrhosis. The 1-, 5-, and 10-year survival rates were 94%, 84%, and 61% for patients with PMVT compared with 88%, 58%, and 26% for those with cirrhosis (non-adjusted HR 0.40, 95% CI 0.19-0.84, p = 0.01, age-adjusted HR 0.51, 95% CI 0.24-1.09, p = 0.08). The survival of patients with PMVT without liver disease trended higher than those with liver disease; however, when adjusted for age, the survival gap narrowed, and the difference was not statistically significant (p = 0.19), survival being lowest for those with PMVT and liver disease. CONCLUSIONS Surgical portosystemic shunts are safe and effective for symptom relief in selected patients with portal hypertension. The odds of graft thrombosis is 9 times higher in patients with PMVT. Overall survival is similar in patients with PMVT or cirrhosis.
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Brunton NE, Wysokinski WE, Hodge DO, Vlazny DT, Houghton DE, Casanegra AI. Delayed anticoagulation in venous thromboembolism: Reasons and associated outcomes. Res Pract Thromb Haemost 2021; 5:e12500. [PMID: 34027287 PMCID: PMC8117818 DOI: 10.1002/rth2.12500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/12/2021] [Accepted: 02/01/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE We assessed the number of cases with delayed anticoagulation initiation, explored the reasons for the delay, and its impact on outcome in patients with acute venous thromboembolism (VTE) treated in an organized setting of treatment initiation and continuous, prospective follow-up. METHODS Patients with anticoagulation initiation delay >24 hours were identified within the cohort of patients with acute VTE enrolled in the Mayo Clinic Venous Thromboembolism Registry between 2013 and 2020. The reasons for treatment delay were explored by reviewing the electronic database. VTE recurrence, all-cause mortality, major bleeding, and clinically relevant nonmajor bleeding (CRNMB) were compared to those with no anticoagulation delay. RESULTS Of 2378 patients with acute VTE, 100 (4.2%) experienced an anticoagulation delay. We identified seven reasons for treatment delays: deferring anticoagulation initiation to specialists (n = 38), thrombocytopenia (n = 10), planned or recent procedure (n = 16), active or recent bleeding (n = 12), missed diagnosis (n = 7), logistics (n = 6), and patient decision (n = 4). In seven cases, no reason was identified. We identified modifiable reasons for anticoagulation delay in 55%. At 90-day follow-up, patients with anticoagulation delay had a higher rate of mortality and major bleeding. VTE recurrence and CRNMB were not statistically different compared to those without anticoagulation delay. After adjustment for age, weight, and cancer, hazard ratios (HRs) for VTE recurrence and major bleeding remained elevated but not to a statistically significant level. CONCLUSION In the setting of a highly organized system of anticoagulation initiation, the incidence of treatment delay is low. Yet most delays could be avoided. A low number of cases provide insufficient power to evaluate the clinical consequences of anticoagulation initiation delay; however, elevated HR for VTE recurrence and major bleeding suggest association and need for further investigation.
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Affiliation(s)
| | - Waldemar E. Wysokinski
- Department of Cardiovascular Medicine Division of Vascular MedicineGonda Vascular CenterMayo ClinicRochesterMNUSA
| | - David O. Hodge
- Department of Health Sciences ResearchMayo ClinicJacksonvilleFLUSA
| | - Danielle T. Vlazny
- Department of Cardiovascular Medicine Division of Vascular MedicineGonda Vascular CenterMayo ClinicRochesterMNUSA
| | - Damon E. Houghton
- Department of Cardiovascular Medicine Division of Vascular MedicineGonda Vascular CenterMayo ClinicRochesterMNUSA
| | - Ana I. Casanegra
- Department of Cardiovascular Medicine Division of Vascular MedicineGonda Vascular CenterMayo ClinicRochesterMNUSA
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Caiano LM, Riva N, Carrier M, Gatt A, Ageno W. Treatment of portal vein thrombosis: an updated narrative review. Minerva Med 2021; 112:713-725. [PMID: 33832217 DOI: 10.23736/s0026-4806.21.07526-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Portal vein thrombosis (PVT) is the most frequent among the splanchnic vein thrombosis, accounting for 90% of cases. More than half of PVT are provoked by liver cirrhosis, solid cancer or myeloproliferative neoplasms. The remaining cases are non-malignant non-cirrhotic PVT and include either unprovoked events or thrombosis secondary to other less common risk factors (e.g. abdominal surgery, intrabdominal inflammations/infections, or hormonal stimuli). Anticoagulant therapy in patients with acute symptomatic PVT should be started early after diagnosis, if no active bleeding, to obtain greater vessel recanalization and reduce the occurrence of portal-hypertension related complications. Gastroesophageal varices do not represent a contraindication to anticoagulant treatment, as long as adequate measures have been undertaken for the prophylaxis of gastroesophageal bleeding. Different treatment options (unfractionated or low molecular weight heparin, vitamin K antagonists and direct oral anticoagulants [DOACs]) can be considered. In this narrative review we will discuss the treatment of PVT in the three most common scenarios (cirrhosis-associated, cancer-associated and non-malignant non-cirrhotic PVT). We will also discuss the role of the DOACs and summarise recent guidelines on this topic.
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Affiliation(s)
- Lucia M Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy.,Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta -
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Kawata E, Siew DA, Payne JG, Louzada M, Kovacs MJ, Lazo-Langner A. Splanchnic vein thrombosis: Clinical manifestations, risk factors, management, and outcomes. Thromb Res 2021; 202:90-95. [PMID: 33798804 DOI: 10.1016/j.thromres.2021.03.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/28/2021] [Accepted: 03/15/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Clinical manifestations and optimal management strategies in patients with splanchnic vein thrombosis (SVT) are not well characterized. METHODS We conducted a retrospective cohort study including all newly diagnosed SVT evaluated between January 2007 and December 2018. Efficacy outcome was thrombosis resolution, and safety outcomes included death and occurrence of bleeding. RESULTS We included 155 patients with a mean age of 56.2 (18-87). Local risk factors were present in 118 (76.1%) patients and 30 (19.4%) had only systemic/thrombophilia. Local risk factors included abdominal cancers (31%), surgery (20.6%) and liver cirrhosis (19.4%). Thrombophilia screening was conducted in approximately 50% of patients. Factor V Leiden or Prothrombin G20210A mutations were observed in 7.1% of patients whereas 14.4% were JAK2V617F mutation positive. Most common manifestations at onset were abdominal pain (56.1%), whereas 44.6% were incidentally found. Portal vein thrombosis was observed more in primary cases (91.9% vs. 69.5%, p = 0.012). Anticoagulation was used in 93.5% cases. Indefinite anticoagulation was used more frequently in primary SVT (62.2% vs. 41.5%, p = 0.045). Thrombosis resolution and bleeding complications among primary (without local risk factors) and secondary (with local risk factors) SVT were observed in 48.5%, 65%, 8.1%, and 11.9%, respectively with no difference when comparing patients treated with direct oral anticoagulants or warfarin and/or low molecular weight heparin (58% vs. 62%, p = 0.326, 9% vs. 12%, p = 0.518). CONCLUSIONS In this cohort anticoagulation resulted in partial or complete thrombosis resolution in a significant proportion of patients with an acceptable bleeding risk regardless local risk factors or type of anticoagulant.
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Affiliation(s)
- Eri Kawata
- Division of Hematology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada; Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Dou-Anne Siew
- Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - James Gordon Payne
- Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Martha Louzada
- Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Michael J Kovacs
- Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Alejandro Lazo-Langner
- Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
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Duceppe E, Lauzon JF, Galliger S, Zhang B, Solomon H, Serrano PE. Incidence and predictors of splanchnic vein thrombosis and mortality following hepatobiliary and pancreatic surgery. J Thromb Haemost 2021; 19:797-804. [PMID: 33249718 DOI: 10.1111/jth.15198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/30/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Intraabdominal surgery is a known risk factor for splanchnic vein thrombosis (SVT). SVT incidence, management, and prognosis after hepatopancreatobiliary surgery are unknown. OBJECTIVES To determine the incidence and prognosis of SVT following hepatopancreatobiliary surgery and describe current practices in anticoagulation for postoperative SVT. PATIENTS/METHODS Multicenter retrospective cohort study of adults undergoing hepatopancreatobiliary surgery. Multivariable analyses for predictors of SVT, major bleeding, and 90-day mortality were performed. RESULTS Of 1815 patients included, 89 (4.9%) had cirrhosis and 1532 (84.4%) had active cancer. The most frequent surgeries were pancreaticoduodenectomy (40.6%), open (30.7%), and laparoscopic (11.0%) liver resection. Sixty (3.3%) patients experienced SVT within 90 days of surgery. Among patients with SVT, 23.3% were symptomatic and 75.0% were treated with therapeutic anticoagulation. Planned duration of anticoagulation averaged 3 to 6 months. By multivariable analysis, SVT predictors were: operative time (adjusted odds ratio [aOR] per hour increase 1.32, 95% confidence interval [CI] 1.20-1.46), cirrhosis (aOR 3.22, 95% CI 1.28-8.10), and postoperative intraabdominal infection (aOR 2.99, 95% CI 1.72-5.19). Postoperative major bleeding occurred in 22.1% of patients and 4.0% died within 90 days. Predictors of postoperative mortality were age (aOR per 10-year increase 1.79, 95% CI 1.38-2.30), operative time (aOR 1.31 (1.17-1.45), cirrhosis (aOR 4.42, 95% CI 1.96-9.96), postoperative intraabdominal infection (aOR 2.66, 95% CI 1.55-4.57), postoperative major bleeding (aOR 4.12, 95% CI 2.36-7.30), and postoperative SVT (aOR 3.15, 95% CI 1.42-6.97). CONCLUSION SVT occurred in 1 in 30 patients after hepatopancreatobiliary surgery and was associated with a 3-fold independent increase in 90-day mortality.
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Affiliation(s)
- Emmanuelle Duceppe
- Department of Medicine, University of Montreal, Montreal, QC, Canada
- Centre Hospitalier de l'Universite de Montreal, Montreal, QC, Canada
| | | | - Steven Galliger
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Betty Zhang
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Pablo E Serrano
- Department of Surgery, McMaster University, Hamilton, ON, Canada
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Riva N, Ageno W. Direct oral anticoagulants for unusual-site venous thromboembolism. Res Pract Thromb Haemost 2021; 5:265-277. [PMID: 33733025 PMCID: PMC7938617 DOI: 10.1002/rth2.12480] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/08/2020] [Accepted: 12/11/2020] [Indexed: 12/25/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are currently the preferred oral anticoagulant treatment for most of the patients with deep vein thrombosis of the lower extremities and/or pulmonary embolism. DOACs have several advantages over vitamin K antagonists, such as availability of fixed dosages, fewer drug interactions, faster onset of action, shorter half-life, and lower risk of major and intracranial bleeding. Although the evidence on the use of DOACs in patients with unusual-site venous thromboembolism (VTE) is limited to a few, small randomized controlled trials, these drugs are increasingly used in clinical practice, and several observational cohort studies have been published recently. This narrative review will describe the latest evidence for the use of the DOACs in patients with thrombosis in atypical locations (splanchnic, cerebral, upper extremity, ovarian, and renal vein thrombosis) and will provide some practical advice for their use in patients with unusual-site VTE.
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Affiliation(s)
- Nicoletta Riva
- Department of Pathology, Faculty of Medicine and SurgeryUniversity of MaltaMsidaMalta
| | - Walter Ageno
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
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Serrao A, Merli M, Lucani B, Aprile F, Fiori L, Gioia S, Breccia M, Riggio O, Chistolini A. Outcomes of long-term anticoagulant treatment for the secondary prophylaxis of splanchnic venous thrombosis. Eur J Clin Invest 2021; 51:e13356. [PMID: 33180323 DOI: 10.1111/eci.13356] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Splanchnic vein thrombosis (SVT) is an uncommon but potentially life-threatening disease usually related to different underlying clinical conditions. The risk of SVT recurrences is high over time in patients with an underlying permanent prothrombotic condition. Vitamin K antagonists (VKA) represent the mainstay of treatment for SVT. Data about the efficacy and safety of direct oral anticoagulants (DOACs) are reported in the literature for the treatment of acute SVT, but less is known about their application for the secondary prophylaxis of venous thromboembolism (VTE). The aim of this study was to assess the efficacy and safety of long-term DOACs therapy in patients at high-risk of thrombosis, compared to VKA. METHODS This is a retrospective single-centre study including 70 patients with SVT on long-term anticoagulant treatment with VKA followed-up at our Units between January 2017 and December 2019. All the patients were at high thrombotic risk defined as the presence of a permanent prothrombotic condition requiring long-term anticoagulation. During follow-up, 28 patients were shifted to DOACs and their clinical outcomes were compared to those of the patients who continued VKA therapy. All the arterial and venous thrombotic events of the splanchnic and extra-splanchnic districts as well as the haemorrhagic adverse events occurring during follow-up were recorded. RESULTS Of the seventy patients enrolled in the study, 36 patients (51.4%) had a single-segment involvement thrombosis (28.5% of portal vein, 7.1% of superior mesenteric vein, 4.3% of splenic vein, 11.5% of hepatic veins) and 34 patients (48.6%) had multi-segment involvement at the time of diagnosis. 42 patients (60%) continued VKA therapy and 28 (40%) were switched to DOACs. Median follow-up was 6 years (range 2-8) during VKA and 1.9 years (range 1-5.2) during DOACs. The incidence of thrombotic events was similar between patients on VKA and those on DOACs. Patients on VKA developed deep vein thrombosis (DVT), and of the patients on DOACs 1 developed NSTEMI and 1 DVT. No major haemorrhagic events occurred. Minor bleedings occurred in 26% of patients on VKA and in none of the DOACs patients (P: 0.09). CONCLUSIONS Our results highlight that DOACs could represent an effective and safe alternative to the VKA for secondary prophylaxis in SVT patients at high risk of thrombosis.
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Affiliation(s)
- Alessandra Serrao
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Manuela Merli
- Gastroenterology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Benedetta Lucani
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Francesca Aprile
- Gastroenterology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Luciano Fiori
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Stefania Gioia
- Gastroenterology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Olivero Riggio
- Gastroenterology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Antonio Chistolini
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
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Kakkos SK, Gohel M, Baekgaard N, Bauersachs R, Bellmunt-Montoya S, Black SA, Ten Cate-Hoek AJ, Elalamy I, Enzmann FK, Geroulakos G, Gottsäter A, Hunt BJ, Mansilha A, Nicolaides AN, Sandset PM, Stansby G, Esvs Guidelines Committee, de Borst GJ, Bastos Gonçalves F, Chakfé N, Hinchliffe R, Kolh P, Koncar I, Lindholt JS, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, De Maeseneer MG, Comerota AJ, Gloviczki P, Kruip MJHA, Monreal M, Prandoni P, Vega de Ceniga M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg 2020; 61:9-82. [PMID: 33334670 DOI: 10.1016/j.ejvs.2020.09.023] [Citation(s) in RCA: 382] [Impact Index Per Article: 76.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Wells PS, Theberge I, Bowdridge J, Kelly E, Kielar A, Forgie MA, John S, van Walraven C. Association of Splanchnic Vein Thrombosis on Survival: 15-Year Institutional Experience With 1561 Cases. J Am Heart Assoc 2020; 9:e016600. [PMID: 33269616 PMCID: PMC7955372 DOI: 10.1161/jaha.120.016600] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Previous studies regarding survival in patients with splanchnic vein thrombosis (SVT) are limited. This study measured overall survival in a large cohort of SVTs through linkage to population-based data. Methods and Results Using a previously derived text-search algorithm, we screened the reports of all abdominal ultrasound and contrast-enhanced computed tomography studies at The Ottawa Hospital over 14 years. Screen-positive reports were manually reviewed by at least 2 authors to identify definite SVT cases by consensus. Images of uncertain studies were independently reviewed by 2 radiologists. One thousand five hundred sixty-one adults with SVT (annual incidence ranging from 2.8 to 5.9 cases/10 000 patients) were linked with population-based data sets to measure the presence of concomitant cancer and survival status. Thrombosis involved multiple veins in 314 patients (20.1%), most commonly the portal vein (n=1410, 90.3%). Compared with an age-sex-year matched population, patients with SVT had significantly reduced survival in particular with local cancer (adjusted relative excess risk for recent cases 12.0 [95% CI, 9.8-14.6] and for remote cases 9.7 [7.7-12.2]), distant cancer (relative excess risk for recent cases 5.7 [4.5-7.3] and for remote cases 5.4 [4.4-6.6]), cirrhosis (relative excess risk 8.2 [5.3-12.7]), and previous venous thromboembolism (relative excess risk 3.8 [2.4-6.0]). One hundred fifty (23.9%) of patients >65 years of age were anticoagulated within 1 month of diagnosis. Conclusions SVT is more common than expected. Most patients have cancer and the portal vein is by far the most common vein involved. Compared with the general population, patients with SVT had significantly reduced survival, particularly in patients with concomitant cancer, cirrhosis, and previous venous thromboembolic disease. Most elderly patients did not receive anticoagulant therapy.
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Affiliation(s)
- Philip S. Wells
- Department of MedicineUniversity of OttawaCanada
- Ottawa Hospital Research InstituteCanada
- School of Epidemiology & Public HealthThe University of OttawaCanada
| | | | | | - Erin Kelly
- Department of MedicineUniversity of OttawaCanada
- ICES uOttawaCanada
- Ottawa Hospital Research InstituteCanada
| | - Ania Kielar
- Ottawa Hospital Research InstituteCanada
- Department of Diagnostic ImagingUniversity of OttawaCanada
- Joint Department of Medical ImagingUniversity of TorontoOntarioCanada
| | - Melissa A Forgie
- Department of MedicineUniversity of OttawaCanada
- Ottawa Hospital Research InstituteCanada
| | - Susan John
- Department of Diagnostic ImagingUniversity of OttawaCanada
| | - Carl van Walraven
- Department of MedicineUniversity of OttawaCanada
- ICES uOttawaCanada
- Ottawa Hospital Research InstituteCanada
- School of Epidemiology & Public HealthThe University of OttawaCanada
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Direct oral anticoagulants for the treatment and prevention of venous thromboembolism in patients with cancer: current evidence. Clin Transl Oncol 2020; 23:1034-1046. [PMID: 33206333 PMCID: PMC8084841 DOI: 10.1007/s12094-020-02506-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 09/28/2020] [Indexed: 12/11/2022]
Abstract
Venous thromboembolic disease (VTED) is a common and clinically important complication in patients with cancer, contributing to its mortality and morbidity. Direct oral anticoagulant agents (DOACs), including direct thrombin inhibitors and direct factor Xa inhibitors, are as effective as vitamin K antagonists for the treatment of VTED and are associated with less frequent and severe bleeding. They have advantages over low-molecular-weight heparin, but comparative long-term efficacy and safety data are lacking for these compounds. Recent randomized clinical trials suggest a role for DOACs in the treatment of VTED in patients with cancer. This review will discuss the existing evidence and future perspectives on the role of DOACs in the treatment of VTE based on the current evidence about their overall efficacy and safety and the limited information in patients with cancer; in addition, we will briefly review their pharmacokinetic properties with special reference to potential interactions.
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Pfrepper C. Paraneoplastic Thromboembolism and Thrombophilia: Significance in Visceral Medicine. Visc Med 2020; 36:280-287. [PMID: 33005653 DOI: 10.1159/000509150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/03/2020] [Indexed: 12/14/2022] Open
Abstract
Background Venous (VTE) and arterial thromboembolism (ATE) are frequent complications of cancer. Risk assessment models (RAM) for stratification of the thrombotic risk in patients with gastrointestinal (GI) cancer have several limitations. Summary While pancreatic and stomach cancer are considered very high risk in all RAM, the risk of colorectal cancer differs between RAM, and esophageal cancer and cholangiocarcinoma were underrepresented or not included in any RAM. In addition, up to 49% of patients with pancreatic cancer develop splanchnic vein thrombosis (SVT). Prophylaxis with low-molecular-weight heparins (LMWH) in ambulatory cancer patients is associated with a positive risk-benefit ratio only in high-risk patients and LMWH have been the standard of care for the treatment of cancer-associated VTE and SVT over the last years. Direct oral anticoagulants (DOAC) have been shown to be equally effective compared to LMWH, but bleedings from the GI tract are more frequent. Therefore, recent guidelines suggest the use of DOAC for VTE treatment and for prophylaxis in ambulatory patients at high risk for VTE, but patients at high risk for bleeding, especially with active luminal cancer, should receive LMWH. Key Messages This review discusses RAM and the current options for prophylaxis and treatment of cancer-associated ATE, VTE, and SVT focusing on GI cancers.
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Affiliation(s)
- Christian Pfrepper
- Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
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