Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xi'an International Medical Center Hospital of Digestive Diseases, Northwestern University, Xi'an, China.
Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwestern University, Xi'an, China.
Am J Gastroenterol. 2021 Jul 1;116(7):1447-1464. doi: 10.14309/ajg.0000000000001194.
Current guidelines recommend anticoagulation as the mainstay of portal vein thrombosis (PVT) treatment in cirrhosis. However, because of the heterogeneity of PVT, anticoagulation alone does not always achieve satisfactory results. This study aimed to prospectively evaluate an individualized management algorithm using a wait-and-see strategy (i.e., no treatment), anticoagulation, and transjugular intrahepatic portosystemic shunt (TIPS) to treat PVT in cirrhosis.
Between February 2014 and June 2018, 396 consecutive patients with cirrhosis with nonmalignant PVT were prospectively included in a tertiary care center, of which 48 patients (12.1%) were untreated, 63 patients (15.9%) underwent anticoagulation, 88 patients (22.2%) underwent TIPS, and 197 patients (49.8%) received TIPS plus post-TIPS anticoagulation. The decision of treatment option mainly depends on the stage of liver disease (symptomatic portal hypertension or not) and degree and extension of thrombus.
During a median 31.7 months of follow-up period, 312 patients (81.3%) achieved partial (n = 25) or complete (n = 287) recanalization, with 9 (3.1%) having rethrombosis, 64 patients (16.2%) developed major bleeding (anticoagulation-related bleeding in 7 [1.8%]), 88 patients (22.2%) developed overt hepatic encephalopathy, and 100 patients (25.3%) died. In multivariate competing risk regression models, TIPS and anticoagulation were associated with a higher probability of recanalization. Long-term anticoagulation using enoxaparin or rivaroxaban rather than warfarin was associated with a decreased risk of rethrombosis and an improved survival, without increasing the risk of bleeding. However, the presence of complete superior mesenteric vein thrombosis was associated with a lower recanalization rate, increased risk of major bleeding, and poor prognosis.
In patients with cirrhosis with PVT, the individualized treatment algorithm achieves a high-probability recanalization, with low rates of portal hypertensive complications and adverse events.
目前的指南建议将抗凝作为肝硬化门静脉血栓形成（PVT）治疗的主要方法。然而，由于 PVT 的异质性，单独抗凝并不总能取得满意的效果。本研究旨在前瞻性评估一种个体化管理算法，该算法采用等待观察策略（即不治疗）、抗凝和经颈静脉肝内门体分流术（TIPS）治疗肝硬化 PVT。
2014 年 2 月至 2018 年 6 月，在一家三级护理中心前瞻性纳入 396 例连续患有非恶性 PVT 的肝硬化患者，其中 48 例（12.1%）未治疗，63 例（15.9%）接受抗凝治疗，88 例（22.2%）接受 TIPS 治疗，197 例（49.8%）接受 TIPS 加 TIPS 后抗凝治疗。治疗方案的决策主要取决于肝病的阶段（是否有症状性门静脉高压）以及血栓的程度和范围。
在中位数为 31.7 个月的随访期间，312 例患者（81.3%）实现了部分（n=25）或完全（n=287）再通，其中 9 例（3.1%）出现再血栓形成，64 例（16.2%）发生大出血（抗凝相关出血 7 例[1.8%]），88 例（22.2%）发生显性肝性脑病，100 例（25.3%）死亡。在多变量竞争风险回归模型中，TIPS 和抗凝与更高的再通率相关。使用依诺肝素或利伐沙班而非华法林进行长期抗凝与再血栓形成风险降低和生存改善相关，而不会增加出血风险。然而，完全性肠系膜上静脉血栓形成与较低的再通率、大出血风险增加和不良预后相关。
在肝硬化合并 PVT 的患者中，个体化治疗方案可实现高概率再通，门静脉高压并发症和不良事件发生率低。
