Interventional treatment should be incorporated in the algorithm for the management of patients with portal vein thrombosis†

We read with interest the in-depth review by Valla on thrombosis and anticoagulation in liver disease.1 In the article, there was only a brief comment on the use of radiological interventional procedures in the algorithm for management of portal vein thrombosis (PVT) in patients with and without cirrhosis. We feel there is a need to clarify the indications, timing, and results of radiological interventional procedures in this group of patients, because the procedures can be very beneficial. Although there is a reduced mortality following variceal bleeding in patients with noncirrhotic portal vein thrombosis compared to those with cirrhosis, the presence of PVT with severe portal hypertension can negatively affect quality of life especially in younger patients and may result in life-threatening complications such as mesenteric infarction.2 Although interventional radiological treatment may not be indicated for PVT with an acute onset, which can be treated with anticoagulation in about 50% of cases,3, 4 the interval allowed for anticoagulation to have a therapeutic effect is not clear. Moreover, when variceal bleeding is recurrent or there is extension of the thrombus despite anticoagulation, in our opinion, transjugular intrahepatic portosystemic shunt (TIPS) should be considered to treat PVT.5 In addition, rare complications such as bile duct compression or repeated cholangitis can benefit from portal decompression.6 Once bleeding from varices has occurred, it is not clear in the review whether the balance of risk between further thrombosis or bleeding is the same as for patients with PVT and varices who have not bled. In practice, many centers will ligate the varices to eradicate them and then consider anticoagulation. In less-developed countries, where PVT is more frequent, managing anticoagulation can be difficult or impossible for patients and clinicians. TIPS can be a technique that allows disruption of the thrombus and can prevent its progression, particularly when there is danger of extension to the superior mesenteric vein (SMV) The latter condition can lead the mesenterial infarction which is an important cause of death in this group and can jeopardize liver transplantation,7 particularly with concomitant presence of cavernous transformation. Therefore, when extension of thrombus into the SMV is encountered in patients who are potential candidates for liver transplantation, recanalization of the portal vein and avoidance of progression of thrombosis is essential. There are two categories of patients from our experience in which TIPS is indicated as a first-line therapy for the treatment of PVT: patients with Budd-Chiari syndrome who develop acute PVT8 and patients with PVT who have undergone transplantation.9 In both situations, there is evidence that the occurrence of PVT is associated with increased mortality, particularly in patients with Budd-Chiari syndrome with rapid hepatic decompensation, which can lead to death in a few days. Finally, placement of TIPS in patients with PVT allows the safe use of anticoagulation to prevent thrombosis in general without a risk of portal hypertensive complications. A recent search of the literature shows that 119 patients (with and without liver disease) have undergone an attempt at TIPS placement for portal hypertensive complications due to PVT or recanalization therapy per se. The success rate ranges from 70%-100%, being 65% in presence of cavernous transformation in the larger series, among which is ours.10 We believe that every patient with portal vein thrombosis should have the option of TIPS considered in the therapeutic algorithm toestablish if specific indications are present. Clearly, skilled interventional radiologists are essential and referral pathways are needed. Prospective studies should evaluate the outcome of TIPS in these patients. Randomized controlled study are not possible due to the low incidence of disease. However prospective studies are needed to evaluate TIPS as part of the management algorithm of patients with PVT. Marco Senzolo*, David Patch , Diego Miotto , Cecilia Ferronato*, Evangelos Cholongitas , Andrew K. Burroughs , * Gastroenterology, Department of Surgical and Gastroenterological Sciences, University Hospital of Padua, Padua, Italy, The Royal Free Sheila Sherlock Liver Centre and Department of Surgery, London, UK, Radiology Section, Department Medical Diagnostic Sciences and Special Therapies, University Hospital of Padua, Padua, Italy.