Alimentary Pharmacology and Therapeutics Letters to the Editors
Letter: management of portal vein thromboses in cirrhosis – authors’ reply A. Kumar, P. Sharma & A. Arora Department of Gastroenterology and Hepatology, Ganga Ram Institute for Postgraduate Medical Education & Research (GRIPMER), Sir Ganga Ram Hospital, New Delhi, India. E-mail: [email protected]
be explored further in prospective randomised trials before it can be recommended widely. Thus, we agree with Dr Mancuso in concluding that presently, management of PVT in cirrhosis should be personalised. In particular, anticoagulation and TIPSS are probably indicated in suitable patients awaiting liver transplantation, mostly to prevent PVT extension, but otherwise avoided.
doi:10.1111/apt.13117
SIRS, We thank Dr Mancuso for his comments1 and his interest in our review article.2 We agree with him that we did not discuss the management of portal vein thrombosis (PVT) in patients with cirrhosis in great detail; the reason for this brevity is lack of data, rather than our inadvertent omission. While there are a host of data on management of PVT in noncirrhotic patients, there are almost no robust data to guide management decisions for PVT in cirrhotic patients. Regarding the role of anticoagulation in patients with cirrhosis with PVT, although there are few reports of successful recanalisation with anticoagulation in selected patients,3, 4 particularly those listed for liver transplantation,5 the data are not robust and hence the AASLD position paper6 states: ‘In the absence of robust data, recommendations for or against routine anticoagulation cannot be made. Decisions will need to be made on a case-by-case basis.’ We recommend that end-stage liver disease patients with PVT, who are on a transplant waiting list, may require anticoagulation especially if they have a documented prothrombotic state, to prevent worsening of thrombosis which would lead to drop-out from the list due to technical unfeasibility.7 However, the risks associated with anticoagulant therapy should be carefully assessed against its benefits.8 Regarding the role of transjugular intrahepatic portosystemic shunt (TIPSS), although, TIPSS has been shown in a few retrospective studies9–11 to be a good option for patients with PVT with cirrhosis, especially those awaiting liver transplantation, we feel that this option should
Aliment Pharmacol Ther 2015; 41: 698–707 ª 2015 John Wiley & Sons Ltd
ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.2 REFERENCES 1. Mancuso A. Letter: management of portal vein thromboses in cirrhosis. Aliment Pharmacol Ther 2015; 41: 698. 2. Kumar A, Sharma P, Arora A. Review article: portal vein obstruction - epidemiology, pathogenesis, natural history, prognosis and treatment. Aliment Pharmacol Ther 2015; 41: 276–92. 3. Amitrano L, Guardascione MA, Menchise A, et al. Safety and efficacy of anticoagulation therapy with low molecular weight heparin for portal vein thrombosis in patients with liver cirrhosis. J Clin Gastroenterol 2010; 44: 448–51. 4. Senzolo M, Ferronato C, Burra P, Sartori MT. Anticoagulation for portal vein thrombosis in cirrhotic patients should be always considered. Intern Emerg Med 2009; 4: 161–2; author reply 163–4. 5. Francoz C, Belghiti J, Vilgrain V, et al. Splanchnic vein thrombosis in candidates for liver transplantation: usefulness of screening and anticoagulation. Gut 2005; 54: 691–7. 6. DeLeve LD, Valla D-C, Garcia-Tsao G; American Association for the Study Liver Diseases. Vascular disorders of the liver. Hepatology 2009; 49: 1729–64. 7. Werner KT, Sando S, Carey EJ, et al. Portal vein thrombosis in patients with end stage liver disease awaiting liver transplantation: outcome of anticoagulation. Dig Dis Sci 2013; 58: 1776–80. 8. Ageno W, Dentali F, Squizzato A. How I treat splanchnic vein thrombosis. Blood 2014; 124: 3685–91. 9. Han G, Qi X, He C, et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosis. J Hepatol 2011; 54: 78–88. 10. D’Avola D, Bilbao JI, Zozaya G, et al. Efficacy of transjugular intrahepatic portosystemic shunt to prevent total portal vein thrombosis in cirrhotic patients awaiting for liver transplantation. Transplant Proc 2012; 44: 2603–5. 11. Luca A, Miraglia R, Caruso S, et al. Short- and long-term effects of the transjugular intrahepatic portosystemic shunt on portal vein thrombosis in patients with cirrhosis. Gut 2011; 60: 846–52.
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Letter: management of portal vein thromboses in cirrhosis – authors’ reply A. Kumar, P. Sharma & A. Arora Department of Gastroenterology and Hepatology, Ganga Ram Institute for Postgraduate Medical Education & Research (GRIPMER), Sir Ganga Ram Hospital, New Delhi, India. E-mail: [email protected]
be explored further in prospective randomised trials before it can be recommended widely. Thus, we agree with Dr Mancuso in concluding that presently, management of PVT in cirrhosis should be personalised. In particular, anticoagulation and TIPSS are probably indicated in suitable patients awaiting liver transplantation, mostly to prevent PVT extension, but otherwise avoided.
doi:10.1111/apt.13117
SIRS, We thank Dr Mancuso for his comments1 and his interest in our review article.2 We agree with him that we did not discuss the management of portal vein thrombosis (PVT) in patients with cirrhosis in great detail; the reason for this brevity is lack of data, rather than our inadvertent omission. While there are a host of data on management of PVT in noncirrhotic patients, there are almost no robust data to guide management decisions for PVT in cirrhotic patients. Regarding the role of anticoagulation in patients with cirrhosis with PVT, although there are few reports of successful recanalisation with anticoagulation in selected patients,3, 4 particularly those listed for liver transplantation,5 the data are not robust and hence the AASLD position paper6 states: ‘In the absence of robust data, recommendations for or against routine anticoagulation cannot be made. Decisions will need to be made on a case-by-case basis.’ We recommend that end-stage liver disease patients with PVT, who are on a transplant waiting list, may require anticoagulation especially if they have a documented prothrombotic state, to prevent worsening of thrombosis which would lead to drop-out from the list due to technical unfeasibility.7 However, the risks associated with anticoagulant therapy should be carefully assessed against its benefits.8 Regarding the role of transjugular intrahepatic portosystemic shunt (TIPSS), although, TIPSS has been shown in a few retrospective studies9–11 to be a good option for patients with PVT with cirrhosis, especially those awaiting liver transplantation, we feel that this option should
Aliment Pharmacol Ther 2015; 41: 698–707 ª 2015 John Wiley & Sons Ltd
ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.2 REFERENCES 1. Mancuso A. Letter: management of portal vein thromboses in cirrhosis. Aliment Pharmacol Ther 2015; 41: 698. 2. Kumar A, Sharma P, Arora A. Review article: portal vein obstruction - epidemiology, pathogenesis, natural history, prognosis and treatment. Aliment Pharmacol Ther 2015; 41: 276–92. 3. Amitrano L, Guardascione MA, Menchise A, et al. Safety and efficacy of anticoagulation therapy with low molecular weight heparin for portal vein thrombosis in patients with liver cirrhosis. J Clin Gastroenterol 2010; 44: 448–51. 4. Senzolo M, Ferronato C, Burra P, Sartori MT. Anticoagulation for portal vein thrombosis in cirrhotic patients should be always considered. Intern Emerg Med 2009; 4: 161–2; author reply 163–4. 5. Francoz C, Belghiti J, Vilgrain V, et al. Splanchnic vein thrombosis in candidates for liver transplantation: usefulness of screening and anticoagulation. Gut 2005; 54: 691–7. 6. DeLeve LD, Valla D-C, Garcia-Tsao G; American Association for the Study Liver Diseases. Vascular disorders of the liver. Hepatology 2009; 49: 1729–64. 7. Werner KT, Sando S, Carey EJ, et al. Portal vein thrombosis in patients with end stage liver disease awaiting liver transplantation: outcome of anticoagulation. Dig Dis Sci 2013; 58: 1776–80. 8. Ageno W, Dentali F, Squizzato A. How I treat splanchnic vein thrombosis. Blood 2014; 124: 3685–91. 9. Han G, Qi X, He C, et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosis. J Hepatol 2011; 54: 78–88. 10. D’Avola D, Bilbao JI, Zozaya G, et al. Efficacy of transjugular intrahepatic portosystemic shunt to prevent total portal vein thrombosis in cirrhotic patients awaiting for liver transplantation. Transplant Proc 2012; 44: 2603–5. 11. Luca A, Miraglia R, Caruso S, et al. Short- and long-term effects of the transjugular intrahepatic portosystemic shunt on portal vein thrombosis in patients with cirrhosis. Gut 2011; 60: 846–52.
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