Review
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 21, 2018; 24(27): 2931-2948
Published online Jul 21, 2018. doi: 10.3748/wjg.v24.i27.2931
Perioperative thromboprophylaxis in liver transplant patients
Lesley De Pietri, Roberto Montalti, Daniele Nicolini, Roberto Ivan Troisi, Federico Moccheggiani, Marco Vivarelli
Lesley De Pietri, Division of Anaesthesiology and Intensive Care Unit, Department of General Surgery, AUSL Reggio Emilia-IRCCS, Reggio Emilia 42123, Italy
Roberto Montalti, Daniele Nicolini, Federico Moccheggiani, Marco Vivarelli, Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
Roberto Ivan Troisi, Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital Medical School, Ghent 185 3K3 9000, Belgium
Roberto Ivan Troisi, Department of Clinical Medicine, Federico II University Naples, Naples 80138, Italy
Author contributions: De Pietri L designed the literature review strategy, critically planned the article structure and wrote the paper; Montalti R, Nicolini D, Moccheggiani F, Troisi RI and Vivarelli M critically reviewed the article and contributed to the literature review.
Conflict-of-interest statement: All authors have no conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Lesley De Pietri, MD, Staff Physician, Division of Anaesthesiology and Intensive Care Unit, Department of General Surgery, AUSL Reggio Emilia-IRCCS, Viale Risorgimento 80, Reggio Emilia 42123, Italy. lesley.depietri@yahoo.it
Telephone: +39-522-296111
Received: March 25, 2018
Peer-review started: March 25, 2018
First decision: April 11, 2018
Revised: May 17, 2018
Accepted: June 22, 2018
Article in press: June 22, 2018
Published online: July 21, 2018
Processing time: 117 Days and 10.1 Hours
Abstract

Improvements in surgical and anesthetic procedures have increased patient survival after liver transplantation (LT). However, the perioperative period of LT can still be affected by several complications. Among these, thromboembolic complications (intracardiac thrombosis, pulmonary embolism, hepatic artery and portal vein thrombosis) are relatively common causes of increased morbidity and mortality. The benefit of thromboprophylaxis in general surgical patients has already been established, but it is not the standard of care in LT recipients. LT is associated with a high bleeding risk, as it is performed in a setting of already unstable hemostasis. For this reason, the role of routine perioperative prophylactic anticoagulation is usually restricted. However, recent data have shown that the bleeding tendency of cirrhotic patients is not an expression of an acquired bleeding disorder but rather of coexisting factors (portal hypertension, hypervolemia and infections). Furthermore, in cirrhotic patients, the new paradigm of ‘‘rebalanced hemostasis’’ can easily tip towards hypercoagulability because of the recently described enhanced thrombin generation, procoagulant changes in fibrin structure and platelet hyperreactivity. This new coagulation balance, along with improvements in surgical techniques and critical support, has led to a dramatic reduction in transfusion requirements, and the intraoperative thromboembolic-favoring factors (venous stasis, vessels clamping, surgical injury) have increased the awareness of thrombotic complications and led clinicians to reconsider the limited use of anticoagulants or antiplatelets in the postoperative period of LT.

Keywords: Anticoagulation; Liver transplantation; Antiplatelets; Thrombosis; Coagulation; Heparin; Thromboelastography; Thromboprophylaxis; Hepatic artery thrombosis; Portal vein thrombosis

Core tip: The improvements in surgical and anesthetic techniques during liver transplantation (LT) have led to such a reduction in transfusion requirements that bleeding risk is no longer the major concern. The increased knowledge of coagulation balance and the reported incidence of thrombotic complications (hepatic artery and portal vein thrombosis, intracardiac thrombosis, pulmonary embolism) in the LT setting have brought attention to perioperative thromboprophylaxis in an attempt to decrease the morbidity and mortality associated with these complications. The major concern of thromboprophylaxis is the risk of bleeding complications in a setting of already unstable hemostasis. Hence, monitoring its administration and the careful selection of the patients to be treated are of great importance.