Update on Management of Portal Vein Thrombosis and the Role of Novel Anticoagulants

Abstract

The clinical management of portal vein thrombosis (PVT) remains ambiguous due to its heterogeneous presentations and its associations with liver disease, malignancy, and hypercoagulable states. The natural history and clinical outcome of PVT are highly variable, dependent upon size, extent and degree of the thrombotic occlusion, as well as the physiological impact of patient comorbidities. While existing clinical guidelines consistently recommend low molecular weight heparin or vitamin K antagonist anticoagulation in cirrhotic patients with symptomatic acute PVT, management of asymptomatic and chronic PVT may need to be determined on a case-by-case basis, factoring in the state of underlying liver disease. In general, patients with PVT and underlying malignancy should be anticoagulated to alleviate symptoms and prevent recurrences that could disrupt the cancer management. However, existing clinical data does not support routine anticoagulation of cirrhotic patients with asymptomatic PVT in the absence of underlying cancer. While low molecular weight heparin and vitamin K antagonist remain the most commonly used agents in PVT, an emerging body of clinical evidence now suggests that direct-acting oral anticoagulants may be used safely and effectively in PVT. As such, direct-acting oral anticoagulants may offer a more convenient anticoagulation alternative for PVT management in future practice.

Portal vein thrombosis in the practice of the internist

“…Группой американских исследователей, М. Wu с соавт. [4] condition. The range of treatment for PVT includes close monitoring without intervention, anticoagulation, thrombolysis, thrombectomy, angioplasty, and transjugular intrahepatic portosystemic shunt.…”

“…Эпидемиология. Уровень заболеваемости ТВВ в мире до настоящего времени не установлен [4]. По данным 23796 аутопсий, выполненных в шведской популяции в 1970-1982 гг., ТВВ был обнаружен в 1 % случаев [5].…”

“…W. Ageno Этиология и патогенез. Возникновение ТВВ связано с рядом этиологических факторов, которые разделяют на две группы: интраабдоминальные (локальные), на долю которых приходится около 70 % случаев, и системные -30 % [2,4,8].…”

“…Ведущими причинами локального ТВВ являются цирроз печени (ЦП), воспалительные и онкологические заболевания органов брюшной полости, в первую очередь -гепатоцеллюлярная карцинома (ГЦК), механическая травма сосудов системы ВВ (в том числе ятрогенная), трансплантация печени и др. [2,4,6,7]. К системным факторам относят врожденные и приобретенные тромбофилии, антифосфолипидный синдром, миелопролиферативные заболевания, полицитемию и т. д.…”

How I treat cancer-associated thrombosis

“…Thrombosis of the portal, mesenteric or splenic veins, summarised as SVT, either symptomatic or incidentally discovered on imaging procedures, can complicate management in patients with cancer, with the highest risk in patients with hepatocellular cancer, cholangiocarcinoma or pancreatic cancer 39. Furthermore, direct tumour ingrowth into splanchnic vessels, also known as tumour thrombus, consisting solely on antineoplastic proliferation, most frequently observed in renal cell carcinoma, might mimic ‘real’ SVT 40.…”