What is the optimal management of thromboprophylaxis after liver transplantation regarding prevention of bleeding, hepatic artery, or portal vein thrombosis? A systematic review of the literature and expert panel recommendations

Abstract

Background A key tenet of clinical management of patients post liver transplantation (LT) is the prevention of thrombotic and bleeding complications. This systematic review investigated the optimal management of thromboprophylaxis after LT regarding portal vein thrombosis (PVT) or hepatic artery thrombosis (HAT) and prevention of bleeding. Methods Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Seven databases were used to conduct extensive literature searches focusing on the use of anticoagulation in LT and its impact on the following outcomes: PVT, HAT, and bleeding (CRD42021244288). Results Of the 2478 articles/abstracts screened, 16 studies were included in the final review. All articles were critically appraised by a panel of independent reviewers. There was wide variation regarding the anticoagulation protocols used. Thromboprophylaxis with therapeutic doses of heparin/Vitamin K antagonist combination did not decrease the risk of de novo or the recurrence of PVT but was associated with an increased risk of bleeding in some studies. Only the use of aspirin resulted in a small but significant decrease in the incidence of HAT post‐LT, yet it did not increase the risk of bleeding. Conclusions Based on existing data and expert opinion, thromboprophylaxis at therapeutic or prophylactic dose is not recommended for prevention of de novo PVT following LT in patients not at high risk. Aspirin should be considered as the standard of care following LT to prevent HAT. Thromboprophylaxis should be strongly considered in recipients at risk of HAT and PVT following LT.

Redo hepatic artery reconstruction for thrombosis without retransplantation in 1355 adult living donor liver transplantations

“…Aspirin, as an antiplatelet prophylaxis, was used to prevent HAT in our institution. A recent systemic review [29] reported that ASA use significantly decreased the incidence of HAT without increasing the bleeding risk. With the exception of a few cases of postoperative bleeding in our experience, most of the medications were usually started from postoperative days 2-3.…”

Portal Vein Thrombosis: State-of-the-Art Review

“…Based on a recent systematic review, thromboprophylaxis at a prophylactic or therapeutic dose is not recommended for PVT prevention after LT in patients without high risk [ 153 , 154 ]. Aspirin should be considered as the standard of care following LT to prevent hepatic artery thrombosis [ 153 , 154 ].…”

Anesthesia and Critical Care for the Prediction and Prevention for Small-for-size Syndrome: Guidelines from the ILTS-iLDLT-LTSI Consensus Conference

“…In a study of 314 adult LT recipients, the estimated risk of developing a deep vein thrombosis (DVT) was found to be >9% even with the use of mechanical prophylaxis. 54 Prophylactic unfractionated heparin was shown to significantly reduce the incidence of DVT and pulmonary embolism within 30 d of LT. 55 ERAS4OLT consensus 56 made a strong recommendation for considering thromboprophylaxis in only recipients at risk of hepatic artery thrombosis and portal vein thrombosis following LT. It was also recommended to strongly consider the use of low-dose subcutaneous unfractionated heparin prophylaxis to prevent DVT/pulmonary embolism in the early postoperative period.…”