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Portal vein thrombosis (PVT) worsens the long-term prognosis of patients with cirrhosis; however, the optimal treatment remains to be determined. Reports on the efficacy of direct oral anticoagulants are increasing, and further evidence is needed. Therefore, we investigated the effectiveness of treatment with edoxaban in patients with PVT. We retrospectively reviewed the outcomes of edoxaban and warfarin as antithrombotic therapies for PVT. The median overall survival time was 4.2 years in patients with PVT, with a 1-year survival rate of 70.7% and a 5-year survival rate of 47.9%. The leading cause of death was hepatocellular carcinoma. The overall response rate for thrombolysis in the edoxaban group was 76.7% compared to 29.4% in the warfarin group, and edoxaban significantly improved PVT compared to warfarin. In addition, edoxaban provided long-term improvement of PVT. Warfarin, on the other hand, was temporarily effective but did not provide long-term benefits. The Child–Pugh and albumin-bilirubin scores did not change after edoxaban or warfarin use. No deaths occurred due to adverse events associated with edoxaban or warfarin. Edoxaban as a single agent can achieve long-term recanalization without compromising the hepatic reserves. Edoxaban is easy to initiate, even in an outpatient setting, and could become a major therapeutic agent for the treatment of PVT. [ABSTRACT FROM AUTHOR]

Background: Portal vein thrombosis (PVT) and venous thromboembolism (VTE) both result from partial or complete occlusion of a blood vessel by a blood clot. The prognosis of PVT is generally good; however, PVT with VTE, including pulmonary embolism (PE), has a high mortality rate. We report here a case of PE after surgery for small intestinal necrosis caused by idiopathic PVT. Case presentation: A 69-year-old female attended our hospital with a chief complaint of upper abdominal discomfort, and was diagnosed with necrosis of the small intestine as a result of unexplained PVT. She underwent partial resection of the small intestine. On the second postoperative day, she suffered from respiratory distress and went into cardiopulmonary arrest. The patient recovered following cardiopulmonary resuscitation, but PE was detected. Extracorporeal veno-arterial cardiopulmonary resuscitation and anticoagulation therapy were initiated immediately and the thrombus was aspirated as much as possible. Two days later, extracorporeal veno-arterial cardiopulmonary resuscitation was withdrawn and anticoagulation therapy was continued. The patient subsequently recovered with no neurological damage and was discharged on day 26 after the above procedure. Conclusions: Idiopathic PVT is often associated with VTE, and a prompt diagnosis and intervention may result in a good prognosis. [ABSTRACT FROM AUTHOR]

Purpose of Review: Portal vein thromboses occur in patients with cirrhosis, including those awaiting liver transplant, and uncertainty exists regarding its prognosis, workup, and optimal management. Recent Findings: The prevalence of PVT is higher in those with more severe liver disease (24% vs 14% for Child-Pugh B/C vs A, respectively). PVT, especially those with complete occlusion, is associated with mortality and graft loss in liver transplant recipients. Increasing data on direct oral anticoagulant (DOAC) use in cirrhosis and specifically for use in patients with PVT provides physicians and patients with more appealing anticoagulation options. In addition to observation and anticoagulation, there is an emerging role of transjugular intrahepatic porto-systemic (TIPS) shunt for recanalization of the portal vein in certain patients, with prospective single-center study demonstrating 98–100% efficacy in those with complete occlusion compared to a lower rate of patency with medical therapy alone (13%). Summary: Due to the complexities involved in assessing and managing PVTs in cirrhosis based on individual patient factors, a multidisciplinary approach with hepatologists, hematologists, interventional radiologists, and transplant surgeons is strongly recommended for patients who are transplant candidates, have recurrent thromboses or complex anatomy, and may be considered in any patient with cirrhosis. [ABSTRACT FROM AUTHOR]

Portal vein thrombosis (PVT) is a common complication of cirrhosis as a result of portal hypertension and modification in the hemostatic balance. Accumulating evidence now suggests that patients with non-alcoholic fatty liver disease (NAFLD), especially those with advanced forms, have an increased risk of PVT. Hence, we performed a meta-analysis of observational studies to estimate the overall prevalence of PVT in patients with NAFLD and its advanced forms compared with patients with advanced liver diseases from other etiologies. We systematically searched PubMed, Scopus and Web of Science databases from the inception date to December 30th 2022, using predefined keywords, to identify observational studies. Meta-analysis was performed using random-effects modeling. We included five observational studies for a total of 225,571 patients. Of these, 26,840 (11.9%) patients had NAFLD, whereas the PVT prevalence was 8.5% (n = 2,280). When compared with patients with advanced liver diseases from other etiologies, patients with NAFLD and its advanced forms had a higher risk of prevalent PVT (OR 1.34, 100% CI 1.07–1.67 p < 0,01). The between-study heterogeneity was substantial (I2 = 88%). This meta-analysis suggests that compared with patients with advanced liver diseases from other etiologies, patient with NAFLD and its advanced forms had a higher risk of prevalent PVT. Further research is required to understand the complex link between NAFLD/NASH and PVT development. [ABSTRACT FROM AUTHOR]

Purposeof Review: To review the clinical and histopathological features of obliterative portal venopathy (OPV). Recent Findings: OPV is one cause of non-cirrhotic portal hypertension and is part of the general group of vascular liver diseases termed porto-sinusoidal vascular disease (PSVD), along with nodular regenerative hyperplasia and incomplete septal fibrosis/cirrhosis. It is increasingly being found on liver biopsies in patients having abnormal liver tests and is reliably diagnosable only by liver biopsy. Radiologically, patients may appear to have a cirrhotic liver but typically their liver tests are normal or mildly abnormal, and the liver function is normal. Summary: Most cases of OPV are idiopathic but it can be seen in collagen vascular diseases, in the setting of portal vein thrombosis, in hematologic disorders, and immunodeficiency syndromes, and as a result of certain medications. Liver biopsy may show subtle histological findings so there must be a keener awareness amongst both clinicians and pathologists of this entity, as well as a discourse alerting the pathologist to the presence of portal hypertension. [ABSTRACT FROM AUTHOR]

Purposeof review: Noncirrhotic portal hypertension (NCPH) consists of a heterogenous group of disorders that lead to portal hypertension (pHTN) in the absence of cirrhosis and can be best understood by their relationship to hepatic vascular anatomy. Here, we discuss the most common of these: portal vein thrombosis, porto-sinusoidal vascular disease, Budd-Chiari syndrome, and hepatic sinusoidal obstruction syndrome. Recent advances: We provide a brief overview of each disorder and highlight recent advances in interventional radiology and surgical treatments. Although the former have improved outcomes, the latter may still be indicated in specific situations. Summary: NCPH requires careful diagnostic and therapeutic evaluation. Treatments are evolving to be less invasive, leading to improved outcomes. [ABSTRACT FROM AUTHOR]

Purpose of Review: The management of non-cirrhotic, non-tumoral portal vein thrombosis (PVT) has historically been challenging due to a paucity of data. The purpose of this review is to summarize the recommendations from major society guidelines and to highlight emerging evidence from recent years. Recent Findings: While direct oral anticoagulants are increasingly used for the treatment of non-cirrhotic PVT, prospective comparison with warfarin or low molecular weight heparin remains uninvestigated in this population. There is growing evidence that optimal treatment requires a tailored approach based on the underlying etiology of PVT, with options ranging from a relatively short course of anticoagulation to an aggressive combined medical/procedural approach. Summary: Anticoagulation remains the mainstay of treatment for non-cirrhotic PVT. Current therapies are effective at reducing the risk of both immediate complications and long-term sequelae. Future studies should focus on refining the preferred approach to treatment based on etiology of PVT. [ABSTRACT FROM AUTHOR]

Background: The incidence of portal vein thrombosis (PVT) at the time of liver transplantation (LT) may be variable and underestimated. Therefore, preoperative diagnosis and stratification of its extension is so relevant for adequate surgical planning. Revascularization of the portal vein graft becomes essential for graft and patient survival after LT. Early stages of PVT may be managed with eversion thrombectomy and end-to-end anastomoses. However, severe PVT (grades 3 and 4) poses significant challenges for patients requiring LT, resulting in more complex surgeries and higher complication rates. To address these complexities, various surgical techniques have been developed, including collateral alternative vessel utilization, renoportal anastomoses, mesoportal jump graft placement, cavoportal hemitranspositions, portal vein arterialization, or even multivisceral transplantation. Purpose: We herein describe the preoperative surgical planning as well as the different surgical strategies possible to treat portal vein thrombosis during LT. Conclusion: A comprehensive preoperative evaluation of PVT is crucial for accurately assessing its extent and severity. This information is vital for proper surgical planning, which ultimately prepares both the surgeon and the patient for potentially complex procedures during LT. The surgical alternatives presented in this technical report offer promising solutions for treating PVT during LT, making it a viable option for selected patients. [ABSTRACT FROM AUTHOR]

Background: Both Budd-Chiari syndrome (BCS) and portal vein thrombosis (PVT) have been linked to various prothrombotic (PT) conditions. The PT profile in Asians is different from the west and there are no nationwide epidemiological surveys from India. Hence, the present meta-analysis was aimed at analyzing the prevalence of acquired and hereditary thrombophilia among Indian patients with non-cirrhotic PVT and BCS. Methods: A comprehensive literature search of Embase, Medline and Scopus was conducted from January 2000 to February 2022 for studies evaluating the prevalence of various PT conditions in Indian patients with PVT and BCS. Pooled prevalence rates across studies were expressed with summative statistics. Results: Thirty-five studies with 1005 PVT patients and 1391 BCS patients were included in the meta-analysis. At least one PT condition was seen in 46.2% (28.7–63.7) of the PVT patients and 44.9% (37.3–60.7) of the BCS patients. Multiple PT conditions were seen in 13.0% (4.2–21.8) of the PVT patients and 7.9% (3.5–12.4) of the BCS patients. Among PVT patients, hyperhomocysteinemia was the commonest prothrombotic condition (21.6%) followed by protein C (PC) deficiency (10.7%), Janus kinase 2 (JAK-2) mutation (8.5%) and antiphospholipid antibodies (APLA) (7.5%). Among patients with BCS, PC deficiency was the commonest prothrombotic condition (10.6%) followed by methylenetetrahydrofolate reductase (MTHFR) mutation (9.8%), APLA (9.7%) and JAK-2 mutation (9.1%). Conclusion: The PT profile in Indian patients with abdominal vein thrombosis is different from that of the western data with a lower prevalence of PT conditions in patients with BCS. [ABSTRACT FROM AUTHOR]

Background and aim: Baveno VII workshop recommends management of acute variceal bleeding (AVB) in cirrhotic patients with nonmalignant portal vein thrombosis (PVT) should be performed according to the guidelines for patients without PVT. Nevertheless, whether PVT affects the outcome of patients with cirrhosis and AVB remains unclear. The aim of this study was to assess the clinical impact of PVT on the outcomes in the pre-emptive TIPSS eligible patients with cirrhosis and AVB. Methods: From December 2010 to June 2016, 1219 consecutive cirrhotic patients admitted due to AVB with (n = 151; 12.4%) or without PVT (n = 1068; 87.6%), who received drug plus endoscopic treatment (a combination of vasoactive drugs, antibiotics, and endoscopic ligation for AVB, followed by beta-blockers plus variceal ligation for prevention of rebleeding) were retrospectively included. Fine and Gray competing risk regression models were taken to evaluate the impact of PVT on clinical outcomes after adjusting for potential confounders. Results: During follow-up, 211 patients (17.3%) died, 490 (40.2%) experienced further bleeding, and 78 (6.4%) experienced new or worsening ascites within 1 year. Compared with those without PVT, patients with PVT had a similar risk of mortality (PVT vs no-PVT: 19.9% vs 16.7% at 1 year; adjusted HR 0.88, 95%CI 0.51–1.52, p = 0.653), further bleeding (47.0% vs 39.2% at 1 year, adjusted HR 1.19, 95% CI 0.92–1.53, p = 183), and new or worsening ascites (7.9% vs 9.6%, adjusted HR 0.70, 95% CI 0.39–1.28, p = 0.253) after adjusting for confounders in multivariable models. These findings were consistent across different relevant subgroups and confirmed by propensity score matching analysis. Conclusions: Our study showed no evidence that the PVT was associated with an improved or worsened outcome among cirrhotic patients with AVB who received standard treatment. [ABSTRACT FROM AUTHOR]

Restorative proctocolectomy with ileal pouch–anal anastomosis is the procedure of choice to maintain intestinal continuity when a total proctocolectomy is a required. It is a technically challenging operation that may be burdened by several nuanced complications both in the immediate postoperative period and in the long term. Most patients with a pouch and any kind of complication will undergo radiological studies, thus multidisciplinary collaboration between surgeons, gastroenterologists, and radiologists is paramount to their timely and accurate diagnosis. When treating pouch patients, radiologists should be familiar with regular pouch anatomy and its appearance in imaging studies, as well as with the most common complications that can occur in this population. In this review, we examine the clinical decision-making process at each step before and after pouch creation, as well as the most common complications associated with pouch surgery, their diagnosis, and their management. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate duplex US findings of the HA in all three postoperative vascular (HA, PV, HV and IVC) complications of paediatric LT for early detection and some helpful secondary signs to determine these vascular complications. Materials and methods: We collected data from 44 post-LT paediatric patients who underwent daily duplex US for seven consecutive days and three months after LT during January 2017–June 2020. Four duplex US parameters of the HA (extrahepatic PSV, intrahepatic PSV, RI and AT) were compared in patients with and without complications. Results: The PSV of the extrahepatic HA in patients with HA complications was higher than that in patients without complications (P value = 0.019). The PSV at 107.7 cm/s is the optimal cut-off parameter associated with HA complications [a sensitivity of 88.9% and a specificity of 80.0% (ROC area is 0.84)]. The intrahepatic RI was higher on the first day than on the last day and gradually decreased in patients without vascular complications (P value = 0.000). The intrahepatic PSV significantly decreased with time when comparing the first and last days in patients without PV and HV-IVC complications (P value = 0.014 and 0.038). In contrast, patients with vascular complications showed no significant decrease. Conclusion: The extrahepatic PSV relates to HA complications after paediatric LT but not PV and HV-IVC complications. Non-significantly decreased intrahepatic RI and PSV from the first day to the day of complication diagnosis may correlate with the occurrence of vascular complications. [ABSTRACT FROM AUTHOR]

Purpose of Review: Portal biliopathy or portal cavernoma cholangiopathy is defined by the presence of cholangiographic abnormalities in a patient with portal cavernoma. In this review, we will examine the evaluation and management of symptomatic portal biliopathy in light of the significant breakthroughs that have been made in this field. Recent Findings: The imaging modality of choice for evaluating portal biliopathy is magnetic resonance cholangiography with portography. Endosonography and cholangioscopy may provide complementary information regarding the etiology of biliary obstruction and should be considered especially when endotherapy is contemplated. Summary: Asymptomatic patients with portal biliopathy do not require an active intervention. In symptomatic patients with cholangitis and biliary calculi, endotherapy is often the initial treatment. However, portosystemic shunt surgery +/− bilioenteric anastomosis (if required) is the definitive treatment in those with shuntable veins. Future studies are required with regard to the management in cases with extensive thrombosis of portal venous system. [ABSTRACT FROM AUTHOR]

Summary: The Billroth IV consensus was developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on the 26th of November 2022 in Vienna. Based on international recommendations and considering recent landmark studies, the Billroth IV consensus provides guidance regarding the diagnosis and management of portal hypertension in advanced chronic liver disease. [ABSTRACT FROM AUTHOR]

Purpose: To review technical details, indications for use, success rates and complications of gun-sight technique for transjugular intra-hepatic portosystemic shunt (TIPS) creation. Materials and Methods: A multicenter retrospective review was performed. Forty-two TIPS procedures with gun-sight technique were identified between 2016 and 2021. Eighty-six percent of patients had portal vein thrombosis (PVT), and 21% had undergone prior failed TIPS creation. Demographics, procedure details and outcomes were reviewed. Differences between the groups, event rates and patency rates were evaluated using nonparametric two-sample Wilcoxon rank-sum (Mann–Whitney) test, Fisher's exact test, Kaplan–Meier curves, and log-rank test. Results: Technical success was 98%. Sixty-seven percent of subjects had transsplenic and 26% had transhepatic access for TIPS creation. Twenty-one adverse events were noted (48%), four of which were definitely related and four were probably related to the use of gun-sight technique. Early (within 90 days) thrombosis occurred in 7/41 patients (17%), all of whom had existing PVT. Conclusion: Gun-sight technique for TIPS creation has a high success rate in this challenging cohort of patients. While complications can occur, most of the adverse events noted were likely associated with TIPS creation itself rather than gun-sight. Early thrombosis only occurred in patients with PVT. Level of Evidence Level 4, Case Series. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of the study was to investigate outcome after pediatric transjugular intrahepatic portosystemic shunt (TIPS) with respect to survival Material and Methods: After searching for studies on TIPS in children in Ovid, Medline, Embase, Scopus and Cochrane published between 2000 and 2022, individual patient data were retrieved from five retrospective cohorts. Overall survival (OS) and transplant-free survival (TFS) were calculated using Kaplan–Meier analysis and log-rank test and compared to the indication (ascites vs. variceal bleeding) as well as to the level of obstruction (pre-hepatic vs. hepatic vs. post-hepatic). Additionally, TIPS patency was analyzed. Results: n = 135 pediatric patients were included in the final analysis. Indication for pediatric TIPS creation was heterogeneous among the included studies. TIPS patency decreased from 6 to 24 months, subsequent pediatric liver transplantation was performed in 22/135 (16.3%) of cases. The presence of ascites was related with poorer TFS (HR 2.3, p = 0.023), while variceal bleeding was not associated with impaired survival. Analysis of the level of obstruction (pre-hepatic, hepatic and post-hepatic) failed to prove significantly reduced OS for post-hepatic obstruction (HR 3.2, p = 0.092) and TFS (HR 1.3, p = 0.057). There was no difference in OS and TFS according to age at time of TIPS placement. Conclusions: The presence of ascites associates with impaired survival after TIPS in children, with no differences in survival according to the age of the child. Interventional shunt procedures can be considered feasible for all ages. Level of Evidence: Level 2a. [ABSTRACT FROM AUTHOR]

Background: To assess the feasibility and safety of a gelfoam torpedo plugging technique for embolization of the transsplenic access channel in adult patients following transvenous portal vein interventions. Materials and methods: Between 09/2016 and 08/2021, an ultrasound guided transsplenic portalvenous access (TSPVA) was established in twenty-four adult patients with a 21-G needle and 4-F microsheath under ultrasound guidance. Afterwards, sheaths ranging from 4-F to 8-F were inserted as needed for the procedure. Following portal vein intervention, the splenic access tract was embolized with a gelfoam-based tract plugging (GFTP) technique. TSPVA and GFTP were performed twice in two patients. Patients' pre-interventional and procedural characteristics were analyzed to assess the feasibility and safety of the plugging technique according Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification system. Values are given as median (minimum;maximum). Subgroup analysis of intercostal vs. subcostal puncture site for TSPVA was performed using the two-sided Mann–Whitney-U test or Student's t-test and Fisher's exact test. Level of significance was p < 0.05. Results: The study population's age was 56 (29;71) years and 54% were female patients. Primary liver disease was predominantly liver cirrhosis with 62% of the patients. Pre-interventional model for end-stage liver disease score was 9 (6;25), international normalized ratio was 1.15 (0.86;1.51), activated partial thromboplastin time was 33s (26s;52s) and platelet count was 88.000/µL (31.000;273.000/µL). Ascites was present in 76% of the cases. Craniocaudal spleen diameter was 17cm (10cm;25cm). Indication for TSPVA was assisted transjugular intrahepatic portosystemic shunt placement in 16 cases and revision in two cases, portal vein stent placement in five cases and variceal embolization in three cases. TSPVA was successfully established in all interventions; interventional success rate was 85% (22/26). The splenic access time was 33min (10min;133min) and the total procedure time was 208min (110min;429min). Splenic access was performed with a subcostal route in 11 interventions and with an intercostal route in 15 interventions. Final sheath size was 4-F in 17 cases, 5-F in three cases, 6-F in five cases, 7-F in two cases and 8-F in one case. A median of two gelfoam cubes was used for GFTP. TSPVA- and GFTP-related complications occurred in 4 of 26 interventions (15%) with a subcapsular hematoma of the spleen in two patients (CIRSE grade 1), access-related infection in one patient (CIRSE grade 3) and both in one patient (CIRSE grade 3). In detail, one access-related complication occurred in a patient with subcostal TSPVA (CIRSE grade 1 complication) and the other three complications occurred in patients with intercostal TSPVA (one CIRSE grade 1 complication and two CIRSE grade 3 complication) (p = 0.614). No patient required interventional or surgical treatment due to puncture tract bleeding. Conclusion: Gelfoam-based plugging of the puncture tract was feasible and safe for transsplenic access in adult patients undergoing percutaneous portal vein interventions. The lack of major bleeding complications and complete absorption of the gelatine sponge make it a safe alternative to transjugular and transhepatic access and re-interventions via the splenic route. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the feasibility, safety, and efficacy of add-on transjugular–intrahepatic–portosystemic shunt (TIPS) for portal vein recanalization (PVR) in cirrhotic patients with non-tumoral chronic portal vein thrombosis (PVT) after 6 months of monitored anticoagulation therapy (ACT). Methods: We conducted a retrospective search of the hospital database for patients who underwent TIPS for persistent PVT despite 6 months of ACT (January 2011 to August 2021). These patients were compared to control group (ACT group; no TIPS but continued on ACT). Post-TIPS periodic assessment was done to look for clinical outcome, PVR (using contrast-enhanced CT scan), and complications. Results: A total of 90 patients were analyzed. Thirty-six patients in TIPS group and 54 patients in ACT group. TIPS was successfully performed in all patients. TIPS group showed complete recanalization of portal vein in 77.8%, partial recanalization in 16.7%, and stable thrombus in 5.5% of the patients. TIPS thrombosis was seen in 3 patients, all underwent successful endovascular thrombolysis. Seven patients developed post-TIPS hepatic encephalopathy and were managed conservatively. In contrast, no patient in ACT group achieved PVR on 12-month follow-up. After propensity score matching, patients in TIPS group showed significantly lower incidence of variceal re-bleeding (22.2% vs. 77.8%, p = 0.03) and refractory ascites (11.1% vs. 51.9%, p < 0.01) with significantly better 12-month survival as compared to ACT group (88.9% vs. 69.4%, p = 0.04). Conclusion: TIPS in cirrhotic patients with PVT result in superior recanalization rates, better control of ascites, and variceal re-bleeding resulting in better survival. TIPS may be considered a preferred therapy after anticoagulation failure. Clinical Impact: TIPS is associated with good technical and clinical success in patients of cirrhosis with PVT and should be considered in patients not responding to ACT. [ABSTRACT FROM AUTHOR]

Background: Diagnosis of tumour thrombosis and differentiating it from benign thrombosis are essential for managing patients, planning treatments, and minimising unneeded anticoagulation therapy. Bland thrombi occur in both cancer and non-cancer patients; tumour thrombi and bland can coexist. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) is useful in detecting and diagnosing tumour thrombosis and distinguishing it from benign thrombosis. Objective: This study's aim was to assess the value of 18F-FDG PET/CT in distinguishing benign from malignant portal vein thrombosis (PVT) in liver cirrhosis patients. Methods: A retrospective study was conducted on 38 patients who had PVT that was histopathologically confirmed and performed 18F-FDG PET/CT scans at our institute between January 2021 and April 2022. For all patients, sociodemographic data, visual analysis, semiqualitative analysis (SUVmax value), and associated hepatic pathology were collected. Results: The SUVmax values were significantly higher in the tumour thrombosis group (6.26 ± 1.94), compared to the bland thrombosis group (1.79 ± 0.69), (P < 0.001). The ROC curve of semiqualitative analysis (SUVmax) revealed a sensitivity of 96.3% and a specificity of 36.4%, at area under curve of 0.827 with SUVmax > 3.5 as the pathological cut-off value to distinguish tumour from bland thrombi. Conclusions: By using semiqualitative analysis, 18F-FDG PET/CT is a valuable new technique in differentiating between neoplastic and bland PV thrombi, with optimal cut-off SUVmax value > 3.5 as a criterion. [ABSTRACT FROM AUTHOR]

Background: In living-donor liver transplantation (LDLT), portal Y-graft interposition using the recipient's portal vein (PV) bifurcation has been used for right lobe grafts with double PV orifices. We herein report the use of thrombectomized autologous portal Y-graft interposition for a recipient with preoperative portal vein thrombosis (PVT) in a right lobe LDLT with double PV orifices. Case presentation: The recipient was a 54-year-old male with end-stage liver disease due to alcoholic liver cirrhosis. There was PV thrombus in the recipient's PV. The living liver donor was his 53-year-old spouse, and a right lobe graft was planned for the transplantation. Since the donor's liver had a type III PV anomaly, autologous portal Y-graft interposition after thrombectomy was planned for PV reconstruction in the LDLT. The portal Y-graft was resected from the recipient and a thrombus extending from the main PV to the right PV branch was removed on the back table. The portal Y-graft was anastomosed to the anterior and posterior portal branches of the right lobe graft. Followed by venous reconstruction, the Y-graft was anastomosed to the recipient's main PV. The operation time was 545 min and the intraoperative blood loss was 1355 ml. The recipient was discharged on postoperative day 13 without any complications. The recipient remains well with the patency of the portal Y-graft one year after the liver transplantation. Conclusion: We herein report the successful use of autologous portal Y-graft interposition after thrombectomy on the back table for a recipient with PVT in a right lobe LDLT. [ABSTRACT FROM AUTHOR]

Introduction: Porto-mesenteric venous thrombosis (PMVT) is a significant complication that occurs more frequently after laparoscopic sleeve gastrectomy (SG) than other bariatric procedures and presents later than other venous thromboembolic (VTE) events often 2 weeks after the operation. The common current practice in bariatric surgery of perioperative chemoprophylaxis until discharge may not adequately prevent PMVT. Therefore, a 30-day post-discharge chemoprophylaxis (PDC) might reduce the incidence of PMVT. The objective of this study is to determine whether 30-day PDC with rivaroxaban 10 mg daily following SG can reduce the incidence of PMVT. Methods: In a retrospective cohort study, 292 consecutive patients undergoing SG by a single surgeon were either prescribed rivaroxaban 10 mg daily for 30 days upon discharge (group A) or did not receive any PDC (group B). Primary outcome was PMVT and secondary outcome was bleeding. Patients on chronic anticoagulation therapy were excluded from the study. Results: PMVT events differences were significant between the groups while bleeding events were not. Group A had zero PMVT events, while group B had four (p =.045). There were 4 bleeding events in group A and 7 bleeding events on group B (p =.341). Conclusion: A 30-day PDC regimen of rivaroxaban 10 mg daily is both safe and effective. This study demonstrated zero PMVT events without an increased risk of bleeding using this regimen. [ABSTRACT FROM AUTHOR]

Background: Porto-sinusoidal vascular disease (PSVD) is a novel nomenclature to describe non-cirrhotic portal hypertension and characteristic histology without portal vein thrombosis (PVT). It is a more inclusive definition than the previously well-recognized entity idiopathic non-cirrhotic portal hypertension. There is a paucity of data on PSVD patients. Methods: A total of 33 patients diagnosed with PSVD and portal hypertension (PH) between 2005 and 2021 were included. Data were retrieved from electronic medical record system and analyzed. Results: Of the 33 patients, 6 (18%) occurred in post-transplant allograft liver. After a median follow-up of 96 months (interquartile range, IQR [52, 139]), 14 deaths occurred (42%), 4 directly related to decompensated liver disease. The Kaplan–Meier survival estimates at 1, 5, and 10 years were 94%, 87% and 58%. PVT occurred in 10 patients (30%). The Nelson–Aalen cumulative risk estimate for PVT at 1, 5 and 10 years were 16%, 25% and 48%. The median model for end-stage liver disease and Child–Pugh score at initial presentation were 8 (IQR [7–12]) and 5 [5–6], and increased to 13 [8, 18] and 7 [5, 8], respectively, at the end of follow-up. Of the 11 patients who presented with splenomegaly and no specific sign of PH, 7 (64%) developed varices and 3 (27%) ascites at a median follow-up of 100 months. Conclusions: PSVD with PH is not a benign entity. Mortality, PVT and hepatic decompensation are common. Patients with PSVD must be closely monitored, including those who only have non-specific clinical signs (e.g., splenomegaly) of PH. [ABSTRACT FROM AUTHOR]

Background: Dengue constitutes a public health problem in endemic regions. The clinical course can range from asymptomatic to severe expressions. Hemorrhagic manifestations are the most frequently reported complications; on the contrary, thrombotic complications are unusual. Clinical case: We present the case of an adult patient who presented hemodynamic instability, severe thrombocytopenia, and positive serology for dengue, in whom acute portal vein thrombosis was documented. The possible pathophysiology of thrombocytopenia and thrombosis in dengue is discussed, as well as the dilemmas regarding the treatment of associated hemorrhagic and thrombotic manifestations. Conclusions: The present case brings up the importance of considering the possibility of thrombotic events in patients with severe dengue. A high degree of suspicion, close assessment of hemostatic function, and quality supportive care are essential to improve outcomes. To our knowledge, this is the first report of dengue-associated portal vein thrombosis. [ABSTRACT FROM AUTHOR]

Background: Marked changes in hemodynamics have been suggested to be a potential contributing factor to portal vein thrombosis (PVT) development. This study investigated the effect of portal hemodynamics based on the anatomical structure of the portal venous system on PVT development. Methods: The morphological features of portal venous system in patients with PVT and those without PVT subgroups were compared. In addition, idealized PV models were established to numerically evaluate the effect of the variation in the angulation of superior mesenteric vein (SMV) and splenic vein (SV) on the hemodynamics of portal venous system. Results: The angle α (angulation of SMV and SV) in patients with PVT was lower than that in patients without PVT (p < 0.0001), which was the only independent risk factor (odds ratio (OR), 0.90 (95% CI 0.84–0.95); p < 0.0001) for the presence of PVT. With the change in angle α, the flow pattern of blood flow changed greatly, especially the helical flow. When α = 80°, helical flow only appeared at the local PV near the intersection of SMV and SV. When α = 120°, most regions were occupied by the helical flow. In addition, the h2 gradually increased with increasing α, when α = 80°, h2 = 12.6 m/s2; when α = 120°, h2 = 29.3 m/s2. Conclusions: The angulation of SV and SMV was closely associated with PVT development. Helical flow changed following the varying angulation of SV and SMV. Therefore, angulation of SV and SMV may help to identify high-risk cohorts for future PVT development earlier. Key points: The angulation of SMV and SV in patients with PVT was lower than that in patients without PVT. With the change in angulation of the SMV and SV, the flow pattern of blood flow changed greatly, especially the helical flow, which is associated with the presence of PVT. The change in portal hemodynamics is associated with the development of PVT. [ABSTRACT FROM AUTHOR]

Background: Portal vein system thrombosis (PVST) is a common postoperative complication brought by laparoscopic splenectomy and pericardial disconnection (LSD) among patients who suffered from portal hypertension and hypersplenism. This research lies mainly in probing into the risk factors of PVST and evaluating the effects of warfarin on PVST prevention. Materials and methods: We took 131 individuals who have carried out LSD from January 2015 to January 2021. Patients were divided into warfarin group (n = 68) and aspirin group (n = 63). Meanwhile, thrombosis factors were analyzed in PVST arm (n = 48) and non-PVST arm (n = 83). Results: We analyzed the early postoperative anticoagulation effect, 20 patients (29.4%) in the warfarin group developed PVST, and 28 patients (44.4%) in the aspirin group. The chance to PVST during the first year after operation was lower in the warfarin group than in the aspirin group (F = 13.43, P = 0.006). Risk factors for PVST were analyzed, and diabetes, the diameter of the portal vein and splenic vein, and the velocity of portal blood flow were statistically significant between the PVST arm and non-PVST arm (P < < 0.05). Multiple logistic regression analyses have shown that diabetes, portal vein diameter, splenic vein diameter, and the velocity of portal blood flow were the risk factors of PVST. Conclusions: The portal vein diameter, splenic vein diameter, portal vein flow velocity, and diabetes are risk factors for the PVST after LSD. The prophylactic use of warfarin anticoagulation markedly decreases the probability of occurrence of the PVST in patients with portal hypertension after LSD compared to aspirin. [ABSTRACT FROM AUTHOR]

Background: Hepatocellular carcinomas (HCC) most commonly complicate liver cirrhosis and it may coexist with malignant portal vein invasion (PVI) that minimizes its possible treatment opportunities and negatively affects its prognosis. However, liver cirrhosis may also be associated with non-tumoral portal vein thrombosis (PVT) particularly in decompensated cirrhosis. Thus, discrimination between tumoral and non-tumoral PVT most preferably by non-invasive imaging techniques is mandatory before treatment decision. Based on the concept of changing tissue elasticity according to tissue pathological changes, Shear wave elastography (SWE) could quantitatively assess tissue stiffness in malignant PVI. We aimed in this work to evaluate the performance of SWE as a novel fast non-invasive diagnostic modality for malignant PVI in cirrhotic patients with HCC. Results: Seventy-eight HCC patients with PVT included in this prospective cross-sectional study, tumoral and non-tumoral PVT were differentiated using triphasic CT and/or dynamic MRI, then SWE was blindly and independently done for all included patients. non-tumoral PVT was present in 21.8% of our HCC patients mostly in decompensated cirrhosis. All of our evaluated predictor factors were evaluated by univariate logistic regression analysis to identify the significant factors in prediction of malignant PVI (SWE, AFP, HCC size, HCC multi-focality, and PVD). By using the multivariate logistic regression we identified that the most independent significant factors were SWE and PVD (sig.: 0.012 and 0.045 respectively). SWE was evaluated versus the criteria of PVT and we found that malignant PVI has significant higher SWE values than benign non-tumoral PVT (sig: 0.012). Two cutoff values were calculated for SWE using ROC curve; the 1st cutoff point was selected to rule in malignant PVI for values ≥ 13 kps, while the 2nd cutoff point was selected to rule out malignant PVI for values ≤ 9 kps with a significant discriminatory performance (AUC: 0.984; sig: 0.000). Conclusions: SWE could be used as a novel fast and non-invasive indicator of malignant portal vein invasion in cirrhotic patients with HCC especially for values ≥ 13 kps and particularly if coexists with larger values of PVD and AFP. [ABSTRACT FROM AUTHOR]

Purpose of Review: This review addresses common clinical scenarios which may require anticoagulation in liver disease patients, the safety and efficacy of direct acting oral anticoagulation (DOAC) agents in liver disease, DOAC dosing considerations based on hepatic or renal impairment, and when anticoagulation should possibly be held or reversed. Recent Findings: The use of DOACs is considered safe and effective compared to traditional therapies like vitamin K antagonists (VKAs) and heparin in patients with liver disease although there is likely an increased risk of bleeding in patients with Child–Pugh B and C. Summary: In the setting of liver disease, anticoagulation with DOAC therapy is considered safe and effective. However, there is likely an increased risk of bleeding in Child-Pugh B and C but further studies are needed to quantify this risk. There is no guidance at this time on DOAC-level monitoring, but future studies evaluating its use may be helpful in liver disease patients. [ABSTRACT FROM AUTHOR]

Objectives: Portal hypertension resulting from non-cirrhotic extrahepatic portal vein obstruction (EHPVO) in children has been primarily managed with the Meso-Rex bypass, but only a few patients have a viable Rex recessus, required by surgery. This study reports a preliminary series of patients who underwent interventional radiology attempts at portal vein recanalization (PVR), with a focus on technical aspects and safety.A retrospective review of consecutive patients with severe portal hypertension due to non-cirrhotic EHPVO at a single institution from 2022, who underwent percutaneous attempts at PVR, was performed. Technical and clinical data including fluoroscopy time, radiation exposure, technical and clinical success, complications and follow-up were recorded.Eleven patients (6 males and 5 females; median age 7 years, range 1–14) underwent 15 percutaneous transhepatic (n = 1), transplenic (n = 11), or simultaneous transhepatic/transplenic (n = 3) procedures. Rex recessus was patent in 4/11 (36%). Fluoroscopy resulted in a high median total dose area product (DAP) of 123 Gycm2 (range 17–788 Gycm2) per procedure. PVR was achieved in 5/11 patients (45%), 3/5 with obliterated Rex recessus. Two adverse events of grade 2 and grade 3 occurred without sequelae. After angioplasty, 4/5 patients required stenting to obtain sustained patency, as demonstrated by colour-Doppler ultrasound in all PVR after a median follow-up of 6 months (range 6–14).Our preliminary experience suggests that 45% of children with non-cirrhotic EHPVO can restore portal flow even with obliterated Rex recessus. In non-cirrhotic EHPVO, PVR may be an option, if a Meso-Rex bypass is not feasible, although the radiation exposure deserves attention.Innovative percutaneous procedures may have the potential to be an alternative option to the traditional surgical approach in the management of non-cirrhotic EHPVO and its complications in children not eligible for Meso-Rex bypass surgery.Non-cirrhotic portal hypertension in children has been traditionally managed by surgery with Meso-Rex bypass creation.Percutaneous PVR may restore the patency of the native portal system even when the Rex recessus is obliterated and surgery has been excluded.Interventional radiological techniques may offer a minimally invasive solution in complex cases of EHPVO in children when Meso-Rex bypass is not feasible.Non-cirrhotic portal hypertension in children has been traditionally managed by surgery with Meso-Rex bypass creation.Percutaneous PVR may restore the patency of the native portal system even when the Rex recessus is obliterated and surgery has been excluded.Interventional radiological techniques may offer a minimally invasive solution in complex cases of EHPVO in children when Meso-Rex bypass is not feasible.Methods: Portal hypertension resulting from non-cirrhotic extrahepatic portal vein obstruction (EHPVO) in children has been primarily managed with the Meso-Rex bypass, but only a few patients have a viable Rex recessus, required by surgery. This study reports a preliminary series of patients who underwent interventional radiology attempts at portal vein recanalization (PVR), with a focus on technical aspects and safety.A retrospective review of consecutive patients with severe portal hypertension due to non-cirrhotic EHPVO at a single institution from 2022, who underwent percutaneous attempts at PVR, was performed. Technical and clinical data including fluoroscopy time, radiation exposure, technical and clinical success, complications and follow-up were recorded.Eleven patients (6 males and 5 females; median age 7 years, range 1–14) underwent 15 percutaneous transhepatic (n = 1), transplenic (n = 11), or simultaneous transhepatic/transplenic (n = 3) procedures. Rex recessus was patent in 4/11 (36%). Fluoroscopy resulted in a high median total dose area product (DAP) of 123 Gycm2 (range 17–788 Gycm2) per procedure. PVR was achieved in 5/11 patients (45%), 3/5 with obliterated Rex recessus. Two adverse events of grade 2 and grade 3 occurred without sequelae. After angioplasty, 4/5 patients required stenting to obtain sustained patency, as demonstrated by colour-Doppler ultrasound in all PVR after a median follow-up of 6 months (range 6–14).Our preliminary experience suggests that 45% of children with non-cirrhotic EHPVO can restore portal flow even with obliterated Rex recessus. In non-cirrhotic EHPVO, PVR may be an option, if a Meso-Rex bypass is not feasible, although the radiation exposure deserves attention.Innovative percutaneous procedures may have the potential to be an alternative option to the traditional surgical approach in the management of non-cirrhotic EHPVO and its complications in children not eligible for Meso-Rex bypass surgery.Non-cirrhotic portal hypertension in children has been traditionally managed by surgery with Meso-Rex bypass creation.Percutaneous PVR may restore the patency of the native portal system even when the Rex recessus is obliterated and surgery has been excluded.Interventional radiological techniques may offer a minimally invasive solution in complex cases of EHPVO in children when Meso-Rex bypass is not feasible.Non-cirrhotic portal hypertension in children has been traditionally managed by surgery with Meso-Rex bypass creation.Percutaneous PVR may restore the patency of the native portal system even when the Rex recessus is obliterated and surgery has been excluded.Interventional radiological techniques may offer a minimally invasive solution in complex cases of EHPVO in children when Meso-Rex bypass is not feasible.Results: Portal hypertension resulting from non-cirrhotic extrahepatic portal vein obstruction (EHPVO) in children has been primarily managed with the Meso-Rex bypass, but only a few patients have a viable Rex recessus, required by surgery. This study reports a preliminary series of patients who underwent interventional radiology attempts at portal vein recanalization (PVR), with a focus on technical aspects and safety.A retrospective review of consecutive patients with severe portal hypertension due to non-cirrhotic EHPVO at a single institution from 2022, who underwent percutaneous attempts at PVR, was performed. Technical and clinical data including fluoroscopy time, radiation exposure, technical and clinical success, complications and follow-up were recorded.Eleven patients (6 males and 5 females; median age 7 years, range 1–14) underwent 15 percutaneous transhepatic (n = 1), transplenic (n = 11), or simultaneous transhepatic/transplenic (n = 3) procedures. Rex recessus was patent in 4/11 (36%). Fluoroscopy resulted in a high median total dose area product (DAP) of 123 Gycm2 (range 17–788 Gycm2) per procedure. PVR was achieved in 5/11 patients (45%), 3/5 with obliterated Rex recessus. Two adverse events of grade 2 and grade 3 occurred without sequelae. After angioplasty, 4/5 patients required stenting to obtain sustained patency, as demonstrated by colour-Doppler ultrasound in all PVR after a median follow-up of 6 months (range 6–14).Our preliminary experience suggests that 45% of children with non-cirrhotic EHPVO can restore portal flow even with obliterated Rex recessus. In non-cirrhotic EHPVO, PVR may be an option, if a Meso-Rex bypass is not feasible, although the radiation exposure deserves attention.Innovative percutaneous procedures may have the potential to be an alternative option to the traditional surgical approach in the management of non-cirrhotic EHPVO and its complications in children not eligible for Meso-Rex bypass surgery.Non-cirrhotic portal hypertension in children has been traditionally managed by surgery with Meso-Rex bypass creation.Percutaneous PVR may restore the patency of the native portal system even when the Rex recessus is obliterated and surgery has been excluded.Interventional radiological techniques may offer a minimally invasive solution in complex cases of EHPVO in children when Meso-Rex bypass is not feasible.Non-cirrhotic portal hypertension in children has been traditionally managed by surgery with Meso-Rex bypass creation.Percutaneous PVR may restore the patency of the native portal system even when the Rex recessus is obliterated and surgery has been excluded.Interventional radiological techniques may offer a minimally invasive solution in complex cases of EHPVO in children when Meso-Rex bypass is not feasible.Conclusion: Portal hypertension resulting from non-cirrhotic extrahepatic portal vein obstruction (EHPVO) in children has been primarily managed with the Meso-Rex bypass, but only a few patients have a viable Rex recessus, required by surgery. This study reports a preliminary series of patients who underwent interventional radiology attempts at portal vein recanalization (PVR), with a focus on technical aspects and safety.A retrospective review of consecutive patients with severe portal hypertension due to non-cirrhotic EHPVO at a single institution from 2022, who underwent percutaneous attempts at PVR, was performed. Technical and clinical data including fluoroscopy time, radiation exposure, technical and clinical success, complications and follow-up were recorded.Eleven patients (6 males and 5 females; median age 7 years, range 1–14) underwent 15 percutaneous transhepatic (n = 1), transplenic (n = 11), or simultaneous transhepatic/transplenic (n = 3) procedures. Rex recessus was patent in 4/11 (36%). Fluoroscopy resulted in a high median total dose area product (DAP) of 123 Gycm2 (range 17–788 Gycm2) per procedure. PVR was achieved in 5/11 patients (45%), 3/5 with obliterated Rex recessus. Two adverse events of grade 2 and grade 3 occurred without sequelae. After angioplasty, 4/5 patients required stenting to obtain sustained patency, as demonstrated by colour-Doppler ultrasound in all PVR after a median follow-up of 6 months (range 6–14).Our preliminary experience suggests that 45% of children with non-cirrhotic EHPVO can restore portal flow even with obliterated Rex recessus. In non-cirrhotic EHPVO, PVR may be an option, if a Meso-Rex bypass is not feasible, although the radiation exposure deserves attention.Innovative percutaneous procedures may have the potential to be an alternative option to the traditional surgical approach in the management of non-cirrhotic EHPVO and its complications in children not eligible for Meso-Rex bypass surgery.Non-cirrhotic portal hypertension in children has been traditionally managed by surgery with Meso-Rex bypass creation.Percutaneous PVR may restore the patency of the native portal system even when the Rex recessus is obliterated and surgery has been excluded.Interventional radiological techniques may offer a minimally invasive solution in complex cases of EHPVO in children when Meso-Rex bypass is not feasible.Non-cirrhotic portal hypertension in children has been traditionally managed by surgery with Meso-Rex bypass creation.Percutaneous PVR may restore the patency of the native portal system even when the Rex recessus is obliterated and surgery has been excluded.Interventional radiological techniques may offer a minimally invasive solution in complex cases of EHPVO in children when Meso-Rex bypass is not feasible.Clinical relevance statement: Portal hypertension resulting from non-cirrhotic extrahepatic portal vein obstruction (EHPVO) in children has been primarily managed with the Meso-Rex bypass, but only a few patients have a viable Rex recessus, required by surgery. This study reports a preliminary series of patients who underwent interventional radiology attempts at portal vein recanalization (PVR), with a focus on technical aspects and safety.A retrospective review of consecutive patients with severe portal hypertension due to non-cirrhotic EHPVO at a single institution from 2022, who underwent percutaneous attempts at PVR, was performed. Technical and clinical data including fluoroscopy time, radiation exposure, technical and clinical success, complications and follow-up were recorded.Eleven patients (6 males and 5 females; median age 7 years, range 1–14) underwent 15 percutaneous transhepatic (n = 1), transplenic (n = 11), or simultaneous transhepatic/transplenic (n = 3) procedures. Rex recessus was patent in 4/11 (36%). Fluoroscopy resulted in a high median total dose area product (DAP) of 123 Gycm2 (range 17–788 Gycm2) per procedure. PVR was achieved in 5/11 patients (45%), 3/5 with obliterated Rex recessus. Two adverse events of grade 2 and grade 3 occurred without sequelae. After angioplasty, 4/5 patients required stenting to obtain sustained patency, as demonstrated by colour-Doppler ultrasound in all PVR after a median follow-up of 6 months (range 6–14).Our preliminary experience suggests that 45% of children with non-cirrhotic EHPVO can restore portal flow even with obliterated Rex recessus. In non-cirrhotic EHPVO, PVR may be an option, if a Meso-Rex bypass is not feasible, although the radiation exposure deserves attention.Innovative percutaneous procedures may have the potential to be an alternative option to the traditional surgical approach in the management of non-cirrhotic EHPVO and its complications in children not eligible for Meso-Rex bypass surgery.Non-cirrhotic portal hypertension in children has been traditionally managed by surgery with Meso-Rex bypass creation.Percutaneous PVR may restore the patency of the native portal system even when the Rex recessus is obliterated and surgery has been excluded.Interventional radiological techniques may offer a minimally invasive solution in complex cases of EHPVO in children when Meso-Rex bypass is not feasible.Non-cirrhotic portal hypertension in children has been traditionally managed by surgery with Meso-Rex bypass creation.Percutaneous PVR may restore the patency of the native portal system even when the Rex recessus is obliterated and surgery has been excluded.Interventional radiological techniques may offer a minimally invasive solution in complex cases of EHPVO in children when Meso-Rex bypass is not feasible.Key Points: Portal hypertension resulting from non-cirrhotic extrahepatic portal vein obstruction (EHPVO) in children has been primarily managed with the Meso-Rex bypass, but only a few patients have a viable Rex recessus, required by surgery. This study reports a preliminary series of patients who underwent interventional radiology attempts at portal vein recanalization (PVR), with a focus on technical aspects and safety.A retrospective review of consecutive patients with severe portal hypertension due to non-cirrhotic EHPVO at a single institution from 2022, who underwent percutaneous attempts at PVR, was performed. Technical and clinical data including fluoroscopy time, radiation exposure, technical and clinical success, complications and follow-up were recorded.Eleven patients (6 males and 5 females; median age 7 years, range 1–14) underwent 15 percutaneous transhepatic (n = 1), transplenic (n = 11), or simultaneous transhepatic/transplenic (n = 3) procedures. Rex recessus was patent in 4/11 (36%). Fluoroscopy resulted in a high median total dose area product (DAP) of 123 Gycm2 (range 17–788 Gycm2) per procedure. PVR was achieved in 5/11 patients (45%), 3/5 with obliterated Rex recessus. Two adverse events of grade 2 and grade 3 occurred without sequelae. After angioplasty, 4/5 patients required stenting to obtain sustained patency, as demonstrated by colour-Doppler ultrasound in all PVR after a median follow-up of 6 months (range 6–14).Our preliminary experience suggests that 45% of children with non-cirrhotic EHPVO can restore portal flow even with obliterated Rex recessus. In non-cirrhotic EHPVO, PVR may be an option, if a Meso-Rex bypass is not feasible, although the radiation exposure deserves attention.Innovative percutaneous procedures may have the potential to be an alternative option to the traditional surgical approach in the management of non-cirrhotic EHPVO and its complications in children not eligible for Meso-Rex bypass surgery.Non-cirrhotic portal hypertension in children has been traditionally managed by surgery with Meso-Rex bypass creation.Percutaneous PVR may restore the patency of the native portal system even when the Rex recessus is obliterated and surgery has been excluded.Interventional radiological techniques may offer a minimally invasive solution in complex cases of EHPVO in children when Meso-Rex bypass is not feasible.Non-cirrhotic portal hypertension in children has been traditionally managed by surgery with Meso-Rex bypass creation.Percutaneous PVR may restore the patency of the native portal system even when the Rex recessus is obliterated and surgery has been excluded.Interventional radiological techniques may offer a minimally invasive solution in complex cases of EHPVO in children when Meso-Rex bypass is not feasible. [ABSTRACT FROM AUTHOR]

Reno-portal anastomosis (RPA) in presence of spleno-renal shunts (SRS) is a physiological option to restore blood flow in liver transplantation with portal vein thrombosis (PVT). Diffuse splanchnic venous system thrombosis (complex PVT) is its main indication but RPA proved to be useful in selected cases of less extensive thrombosis (non-complex PVT). Up until now only two monocentric and one multicentric case series has been published on this topic in addition to few anecdotal reports. After 2014, we introduced RPA in our institution to manage some cases of complex PVT in presence of SRS. Here, we present the evolution of indication to RPA. From 2014 to 2020, we performed ten RPA: nine patients presented non-complex and one complex PVT. Overall early and late complication rates were 66.6% and 50%, respectively. Two patients developed RPA stenosis, treated by interventional radiology. Self-resolving acute kidney injury (AKI) was observed in three cases. No re-transplantation was necessary. RPA was patent in all patients, with a mean follow-up of 41.9 months. The overall patient survival was 70% at 1 year and 60% at 3 and 5 years. Four patients died at 1, 2, 3 and 20 months from LT. Causes of deaths were, respectively, stroke, cerebral infection, sepsis (MOF) and sudden variceal bleeding in sinusoidal obstruction syndrome. The relative simplicity and effectiveness of RPA in presence of SRS allowed us to rely more and more often on this technique in liver transplantation with challenging non-complex PVT. [ABSTRACT FROM AUTHOR]

This article presented an overview of the therapeutic effects of Chinese medicine (CM) preparations for promoting blood circulation and removing blood stasis for patients with portal vein thrombosis (PVT) after splenectomy. Based on published clinical researches of CM preparations for PVT after splenectomy in patients with cirrhotic portal hypertension (CPH), this paper evaluated the incidence of PVT, and explored potential active components and mechanisms of CM preparations. Safflower Yellow Injection, Danshen Injection (丹参注射液) Danhong Injection (丹红注射液), and Compound Danshen Dropping Pill (复方丹参滴丸) achieved good curative effect alone or combined with anticoagulant therapy. In addition, Compound Biejia Ruangan Tablet (复方鳖甲软肝片) and Anluo Huaxian Pill (安络化纤丸) can also significantly improve the hemodynamic disorders of portal vein system in patients with cirrhosis. Considering the role of CM preparations in ameliorating the incidence of PVT after splenectomy in patients with CPH, we suggested that future research should provide more attention to CM alone or CM combined with anticoagulant for cirrhosis with PVT. [ABSTRACT FROM AUTHOR]

Background: Hypersplenism, one of the major complications of portal hypertension, is traditionally treated by splenectomy. However, partial splenic artery embolization is an evolving minimally invasive intervention to treat these patients effectively. Case presentation: A 13-year-old girl was referred for further evaluation of isolated splenomegaly with pancytopenia. She did not have bleeding manifestations or features of anemia. She never had hematemesis or melena. On examination, she was pale. Abdominal examination revealed massive splenomegaly of 10 cm below the costal margin without hepatomegaly. Rest of the examination was unremarkable. Her investigations revealed a white cell count of 1700/mm3 (neutrophils 9.8% and lymphocytes 88.7%), hemoglobin 9.5 g/dL and platelet count 42,000/mm3. Blood picture showed pancytopenia without abnormal cells. Her reticulocyte count was 1.9%. Complete liver profile was normal. Abdominal ultrasonography revealed massive splenomegaly with the oblique length of 17 cm and normal echogenic liver with normal size. Cavernous transformation of portal vein with portal hypertension was evident. Mesenteric angiogram showed portal vein thrombosis and markedly tortuous splenic artery. Anti-nuclear antibodies and double-stranded DNA were negative. Ham test and urine for hemosiderin were negative. Clauss fibrinogen assay was normal. Hemoglobin high performance liquid chromatography for hemoglobin subtypes was normal. Anti-phospholipid antibodies were negative. JAK2 V617F mutation was not identified. Diagnosis of pre hepatic portal hypertension was made. Her upper gastrointestinal endoscopy was normal. Partial splenic artery coil embolization was done by interventional radiology team. Vaccines against capsulated organisms were given. Post-procedure contrast abdominal computed tomography revealed infarction of approximately 70% of the spleen and blood counts were improved. Index case is in the follow up for 3 years. She is on penicillin prophylaxis with regular blood count and annual upper gastrointestinal endoscopy monitoring. Conclusions: Minimally invasive interventions such as partial splenic artery embolization should be considered in managing the patients with hypersplenism secondary to portal hypertension. [ABSTRACT FROM AUTHOR]

Background: The thrombosis of the main and intrahepatic branches of the portal vein (TMIP) is potentially lethal and deemed a common complication following laparoscopic splenectomy and azygoportal disconnection (LSD) in patients with cirrhosis and portal hypertension (PH). The predictors of TMIP after LSD remain unclear. The aim of this prospective study was to explore the predictive and risk factors for TMIP after LSD in cirrhotic patients with PH caused only by hepatitis B virus.Methods: From September 2014 to March 2017, we enrolled 115 patients with hepatitis B cirrhosis and PH who successfully underwent LSD. Patients were subdivided into a TMIP group and a non-TMIP group. Univariate and multivariate logistic regression analysis was conducted on 24 items of demographic and preoperative data, to explore the risk factors of TMIP.Results: Twenty-nine (25.22%) patients developed TMIP on postoperative day (POD) 7 and 26 (22.81%) patients developed TMIP on POD 30. From POD 7 to POD 30, 12 patients who did not have TMIP at POD 7 were newly diagnosed with TMIP, with portal vein diameter 15.05 ± 2.58 mm. Another 14 patients in whom TMIP had resolved had portal vein diameter 14.02 ± 1.76 mm. Univariate analysis and multivariate logistic regression revealed that portal vein diameter ≥ 13 mm [relative risk (RR) 5.533, 95% confidence interval (CI) 1.222-25.042; P = 0.026] and portal vein diameter ≥ 15 mm (RR 3.636, 95% CI 1.466-9.021; P = 0.005) were significant independent risk factors for TMIP on POD 7 and 30, respectively.Conclusion: Portal vein diameter ≥ 13 mm and ≥ 15 mm were significant independent predictors for TMIP after LSD in patients with hepatitis B cirrhosis and PH on POD 7 and POD 30, respectively.Trial Registration: We registered our research at https://www.Clinicaltrials: gov/ . The name of research registered is "Warfarin Prevents Portal Vein Thrombosis in Patients After Laparoscopic Splenectomy and Azygoportal Disconnection." The trial registration identifier at clinicaltrials.gov is NCT02247414. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive splenectomy is now well established for a wide range of pathologies. Portal vein thrombosis (PVT) is increasingly being recognised as a complication of splenectomy. The aim was to determine the incidence and risk factors for PVT after laparoscopic splenectomy. Methods: All cases of elective laparoscopic splenectomy performed from 1993 to 2020 were reviewed. Parameters recorded included demographics, diagnostic criterion and post-operative outcomes. Data were analysed using Minitab V18 with a p < 0.05 considered significant. Results: 210 patients (103 female, 107 male) underwent laparoscopic splenectomy (14 to 85 years). A major proportion of cases were performed for ITP (n = 77, p = 0.012) followed by lymphoma (n = 28), indeterminate lesions (n = 21) and myelofibrosis (n = 19). Ten patients developed symptomatic portal vein thrombosis (4.8%). Patients presented most commonly with pain and fever and diagnosis was confirmed by computed tomography (CT) or ultrasonography (USS). There were 10 conversions (4.8%) to open and two postoperative deaths, one from PVT and one from pneumonia. The remaining nine patients were successfully treated with anticoagulation. Of 19 patients with myelofibrosis, six patients developed PVT (p = 0.0002). Patients who developed PVT had significantly greater specimen weights (1773 g vs 348 g, p < 0.001). Forty-three patients had a specimen weight of 1 kg or greater, and of these 9 developed portal vein thrombosis (21%), versus one with PVT of 155 with a specimen weight of less than 1 kg (p < 0.0001). Myelofibrosis (p = 0.0039), specimen weight (p < 0.001) and mean platelet count (p = 0.0049) were predictive of PVT. Conclusion: A high index of suspicion for this complication should be maintained and prompt treatment with anticoagulation. High-risk patients should be considered for prophylactic anticoagulation and routine imaging of the portal vein. [ABSTRACT FROM AUTHOR]

Purpose: To assess the feasibility, safety and effectiveness of portal vein recanalization (PVR)-transjugular portosystemic shunt (TIPS) placement via splenic access using a balloon puncture technique.Materials and Methods: In a single-center retrospective study from March 2017 to February 2021, 14 consecutive patients with portal hypertension, chronic liver disease and portal vein occlusion or near-complete (> 95%) occlusion were referred for PVR-TIPS placement. Feasibility, safety and effectiveness including procedural characteristics such as technical success, complication profile and splenic access time (SAT), balloon positioning time (BPT), conventional portal vein entry time (CPVET), overall procedure time (OPT), fluoroscopy time (FT), dose-area product (DAP) and air kerma (AK) were evaluated.Results: Transsplenic PVR-TIPS using balloon puncture technique was technically feasible in 12 of 14 patients (8 men, 49 ± 13 years). In two patients without detectable intrahepatic portal vein branches, TIPS placement was not feasible and both patients were referred for further treatment with nonselective beta blockers and endoscopic variceal ligation. No complications grade > 3 of the Cardiovascular and Interventional Radiological Society of Europe classification system occurred. The SAT was 25 ± 21 min, CPVET was 33 ± 26 min, the OPT was 158 ± 54 min, the FT was 42 ± 22 min, the DAP was 167.84 ± 129.23 Gy*cm2 and the AK was 1150.70 ± 910.73 mGy.Conclusions: Transsplenic PVR-TIPS using a balloon puncture technique is feasible and appears to be safe in our series of patients with obliteration of the portal vein. It expands the interventional options in patients with chronic PVT. [ABSTRACT FROM AUTHOR]

Background: Pouchitis is the most common long-term complication in patients requiring colectomy ileal pouch-anal anastomosis with medically refractory ulcerative colitis or colitis-associated neoplasia. A previous small case series suggests associated between portal vein thrombosis (PVT) and ischemic pouchitis. Aim: To evaluate the association between PVT and other demographic and clinical factors and pouchitis. Methods: We used Explorys Inc., a population-based database, to search medical records between 1999 and 2020 with SNOMED-CT code criteria for "construction of pouch" and "ileal pouchitis." Patients with pouchitis were compared to those with previous pouch construction without pouchitis. Factors associated with pouchitis identified with univariable analysis were introduced into a multivariable model. A post hoc analysis further stratified demographical findings of the association between PVT and pouchitis. Results: We identified 7900 patients with ileal pouchitis (7.5%) and 97,510 with pouch construction without pouchitis. In multivariate binary logistic regression, adjusted odds ratio (aOR) for the risk of pouchitis in patients with PVT was 10.78 (95% confidence interval [CI] 7.04–16.49, P < 0.001). Other significant factors associated with pouchitis included male gender (aOR 1.11, 95% CI 1.02–1.21, P = 0.018), deep vein thrombosis (aOR 1.46, 95% CI 1.23–1.72, P < 0.001), and the use of non-steroidal anti-inflammatory drugs (aOR 1.37, 95% CI 1.28–1.45, P < 0.001). Smoking was a protective factor (aOR 0.30, 95% CI 0.33–0.36, P < 0.001). Further sub-analysis showed a higher prevalence of younger patients with PVT and pouchitis. Conclusions: We report PVT as an independent risk factor associated with pouchitis. Our findings support that PVT is a potentially manageable perioperative complication, and intervention may reduce the risk of pouchitis. [ABSTRACT FROM AUTHOR]

Purpose: To compare the safety and outcome of transjugular versus percutaneous technique in recanalization of non-cirrhotic, non-malignant portal vein thrombosis. Methods: We present a retrospective bicentric analysis of 21 patients with non-cirrhotic, non-malignant PVT, who were treated between 2016 and 2021 by interventional recanalization via different access routes (percutaneous [PT] vs. transjugular in transhepatic portosystemic shunt [TIPS] technique). Complication rates with a focus on periprocedural bleeding and patency as well as outcome were compared. Results: Of the 21 patients treated (median age 48 years, range of 19–78), seven (33%) patients had an underlying prothrombotic condition. While 14 (57%) patients were treated for acute PVT, seven (43%) patients had progressive thrombosis with known chronic PVT. Nine patients underwent initial recanalization via PT access and twelve via TIPS technique. There was no significant difference in complete technical success rate according to initial access route (55.5% in PT group vs. 83.3% in TIPS group, p = 0.331). However, creation of an actual TIPS was associated with higher technical success in restoring portal venous flow (86.6% vs. 33.3%, p = 0.030). 13 (61.9%) patients received thrombolysis. Nine (42.8%) patients experienced hemorrhagic complications. In a multivariate analysis, thrombolysis (p = 0.049) and PT access as the first procedure (p = 0.045) were significant risk factors for bleeding. Conclusion: Invasive recanalization of the portal vein in patients with PVT and absence of cirrhosis and malignancy offers a good therapeutic option with high recanalization and patency rates. Bleeding complications result predominantly from a percutaneous access and high amounts of thrombolytics used; therefore, recanalization via TIPS technique should be favored. [ABSTRACT FROM AUTHOR]

Background: PVT is an ultrasonographic finding in up to 8% of patients with liver cirrhosis. Once hepatocellular carcinoma has occurred as the final station in liver cirrhosis, the risk of PVT rises to 40%. Benign and malignant PVT can occur in patients with liver cirrhosis, and it is important to differentiate the nature of PVT as it has a great impact on patient's management and outcome. Diagnosis: Confirming portal vein thrombosis and extension by abdominal ultrasound, contrast-enhanced USG, CT, or MRI. Malignant criteria of PVT are pulsatile pattern in Doppler and heterogeneous contrast enhancement, which are especially seen at the arterial phase, neovascularity within PVT, portal vein thrombus with a diameter of > 23 mm while in benign thrombus, PV diameter does not exceed 20 mm. Visible hypervascular tumor is in close proximity to PVT. Conclusion: It is not uncommon to find portal vein thrombosis in patients with liver cirrhosis, despite the fact that malignant variant is the most frequent, but efforts should be gathered to exclude benign PVT which may change the management of the patients dramatically. [ABSTRACT FROM AUTHOR]

Purpose: To date, the optimal treatment for portal vein thrombosis (PVT) in cirrhotic patients has not been established in guidelines or consensus. We conducted a systematic review and meta-analysis to evaluate the effect of anticoagulation therapy in patients with cirrhosis and PVT. Methods: PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched (until 31st October 2020) for studies evaluating the effect of anticoagulation therapy on treating PVT in patients with cirrhosis. Odds ratios (ORs) and their 95% confidence intervals (CIs) were pooled using the Mantel–Haenszel method. Results: A total of 13 studies were included in the analysis, comprising 6005 patients. Of these, three were prospective cohort studies, nine were retrospective cohort studies and one was case–control study. Compared to no treatment, anticoagulation therapy was associated with higher rates of PVT recanalization (OR 4.29; 95% CI 3.01–6.13). Anticoagulation therapy demonstrated a significant 74% reduction in PVT extension compared to no treatment (OR 0.26; 95% CI 0.14–0.49). Anticoagulation therapy was associated with a nonsignificantly lower risk of death (OR 0.53; 95% CI 0.20–1.40). However, anticoagulation therapy was associated with slightly higher risk of bleeding compared to no treatment (OR 1.16; 95% CI 1.02–1.32). Conclusions: In cirrhotic patients with PVT, anticoagulation therapy helps increase rate of PVT recanalization and improve survival, but may also carry higher risks of bleeding compared to no treatment. Our findings support the use of anticoagulation in cirrhotic patients with PVT. [ABSTRACT FROM AUTHOR]

Purpose of Review: Portal vein thrombosis (PVT) is a frequent consequence of cirrhosis and its management is variable and controversial. Herein we highlight interventional treatment options and outcomes, together with mention of the physiology, presentation and imaging of PVT. Recent Findings: Utilization of transjugular intrahepatic portosystemic shunt (TIPS) for acute and chronic PVT is expanding. In acute PVT, TIPS improves hepatopetal flow which promotes thrombus resorption and prevents rethrombosis. The TIPS also functions as a conduit for thrombectomy devices and allows for embolization of variceal shunts. Chronic PVT is a relative contraindication to liver transplant. Portal vein recanalization (PVR) TIPS restores flow in a previously occluded portal vein, allowing for a conventional end-to-end portal vein anastomosis at transplant. PVR TIPS is technically demanding and often requires percutaneous splenic vein access for portal venous recanalization. Summary: Selection of endovascular PVT treatment varies with the age (acute or chronic) and the extent of thrombus, along with presenting symptoms and transplant candidacy. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study is to assess the added diagnostic value of Doppler ultrasound of the liver (DUL) performed within 3 days of contrast-enhanced CT (CECT) for the diagnosis of portal vein (PV) or hepatic vein (HV) thrombosis. Methods: Adult patients were included if they underwent DUL within three days after a CECT of the abdomen in the emergency or inpatient setting. Retrospective review of clinical data and imaging reports was performed. In patients with discrepant or positive findings on CECT and/or DUL with respect to PV or HV thrombosis, image review was performed by three fellowship-trained abdominal radiologists in consensus. Results: The final cohort consisted of 468 patients. Of these, 26 (5.6%) patients had equivocal findings for thrombosis on CECT, and DUL could make a confident diagnosis of positive or negative in 18 (69%) patients. Additionally, there were 2 (0.4%) patients with PV or HV thrombosis on DUL following a limited CECT, and 2 (0.4%) patients who developed interval PV thrombosis between CECT and DUL. Conclusion: DUL after CECT added diagnostic value for PV and/or HV thrombosis in less than 5% of patients. The patency of PV and HV is often not explicitly mentioned in CECT reports at our institution, which may lead to uncertainty for the referring provider as to whether the PV and HV were adequately evaluated. Few CECT have false positive or missed or underreported findings, and a careful review of the original CECT should be performed if DUL is requested. [ABSTRACT FROM AUTHOR]

Background: Living donor liver transplant (LDLT) for hepatocellular carcinoma (HCC) has been controversial in terms of selection and outcome. We share our experience of LDLT for HCC in Indian patients. Methods: Retrospective analysis of patients undergoing LDLT for HCC discovered either preoperatively or incidentally on explant pathology was done. Preoperative characteristics and explant histopathology findings were recorded. Overall, recurrence-free survival and factors predicting recurrence were analyzed. Results: Six hundred and eleven LDLT were performed between June 2011 and October 2019. HCC constituted 6.5% (n = 53) of transplant activity. Forty had preoperative diagnosis, while 13 were detected incidentally. The median model for end-stage liver disease (MELD) score was 18 for patients with HCC. Only in 10 patients (19%), HCC was the primary indication for liver transplant (LT), and the rest had undergone transplant for progressive decompensation. Thirty-two patients were within up-to-7, while 21 were outside up-to-7 criteria. Overall 5-year survival was 85.4% and recurrence-free survival was 83.3% after a median follow-up of 35 months (13–59). This was similar to LDLT for other indications (81.2% at 5 years). Risk Estimation of Tumor Recurrence After Transplant (RETREAT) score was best able to predict recurrence (p = 0.03) with odds ratio of 6.8. Conclusion: Patients with HCC in India present late for liver transplant. Most patients have some form of decompensation before they undergo LT. In selected patients, overall survival was comparable with other indications for LDLT with acceptable recurrence rates. RETREAT score was best to predict recurrence. [ABSTRACT FROM AUTHOR]

Background: Portal vein thrombosis (PVT) is an infrequent, yet potentially lethal, complication of bariatric surgery. The aim of this prospective, non-randomized, cohort study is to compare between laparoscopic sleeve gastrectomy (LSG) and laparoscopic one-anastomosis gastric bypass (LOAGB) in terms of their early postoperative effects on portal venous flow and patency. Methods: Forty-nine morbidly obese patients were allocated to one of 2 groups (A or B). Group A patients underwent LSG, whereas group B patients underwent LOAGB. Portal venous Doppler ultrasound scanning was performed preoperatively and 2 weeks postoperatively in all cases, in order to assess the portal venous flow (PVF) in terms of flow direction and peak systolic velocity (PSV); as well as to assess the portal venous patency and exclude PVT. The mean change in PSV (ΔPSV) and the mean percentage change in PSV (%ΔPSV) were determined in both groups. Results: In all cases (group A (n = 26); group B (n = 23)), the direction of PVF was "hepatopetal" both preoperatively and 2 weeks postoperatively. The mean ΔPSV and the mean %ΔPSV were higher in LSG patients "group A" (− 0.84 cm/s and 3.25% respectively) compared with LOAGB patients "group B"(− 0.06 cm/s and 0.27% respectively); P = 0.038 and 0.039 respectively. The mean change in PSV was in the negative direction in both groups, i.e., "deceleration." No cases of PVT were reported in the study. Conclusions: Laparoscopic sleeve gastrectomy is associated with greater reduction in portal venous peak systolic flow velocity in the early postoperative period, compared with laparoscopic one-anastomosis gastric bypass. [ABSTRACT FROM AUTHOR]

Purpose: Portal venous system thrombosis is a complication of partial splenic artery embolization, and pre-treatment risk assessment is thus important. The purpose of this study was to identify the risk factors for portal venous system thrombosis after partial splenic artery embolization. Materials and methods: We retrospectively analyzed 67 consecutive patients who underwent contrast-enhanced computed tomography before and after first partial splenic artery embolization between July 2007 and October 2018. As risk factors, we investigated age, sex, hematological data, liver function, steroid use, heparin use, and findings from pre- and post-treatment computed tomography. Uni- and multivariate analyses were performed to evaluate the relationship between thrombus appearance or growth and these factors. Values of p < 0.05 were considered significant. Results: Partial splenic artery embolization was technically successful in all 67 patients. Nine patients showed appearance or growth of thrombus. Univariate analysis showed maximum diameter of the splenic vein before treatment (p = 0.0076), percentage of infarcted spleen (p = 0.017), and volume of infarcted spleen (p = 0.022) as significant risk factors. Multivariate analysis showed significant differences in maximum diameter of the splenic vein before treatment (p = 0.041) and percentage of infarcted spleen (p = 0.023). According to receiver operating characteristic analysis, cutoffs for maximum diameter of the splenic vein and percentage of infarcted spleen for distinguishing the appearance or growth of thrombus were 17 mm and 58.2%. Conclusion: Large maximum diameter of the splenic vein before partial splenic artery embolization and high percentage of infarcted spleen after partial splenic artery embolization were identified as risk factors for portal venous system thrombosis. Level of Evidence: Level 4, Case Series [ABSTRACT FROM AUTHOR]

Purpose: Portal vein thrombosis (PVT) following hepatectomy is potentially life-threatening. We aimed to evaluate the incidence of PVT after hepatectomy for hepatocellular carcinoma and identify coagulation and fibrinolytic factors that could predict early-stage postoperative PVT. Methods: A retrospective analysis was conducted on 65 hepatocellular carcinoma patients who underwent radical hepatectomy. The risk factors for postoperative PVT were identified based on univariate and multivariate analyses, and the levels of coagulation and fibrinolytic factors were measured during the perioperative period. Results: The incidence of PVT after hepatectomy was 20.0%. The patients were divided into two groups: those with PVT (n=13; PVT group) and those without PVT (n=52; no-PVT group). The frequency of the use of the Pringle maneuver during surgery was higher in the PVT group than in the no-PVT group, and the postoperative/preoperative ratios of thrombin-antithrombin III complex (TAT) and of D-dimer were significantly higher in the PVT group. Conclusion: A high incidence of PVT was found in hepatocellular carcinoma patients after hepatectomy. The frequency of the Pringle maneuver is a potential risk factor for postoperative PVT, and the postoperative/preoperative TAT and D-dimer ratios may be used as early predictors of PVT after hepatectomy for hepatocellular carcinoma. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has rapidly spread worldwide. As it is a novel disease, we have less experience in its possible appearances. Predominantly affecting the respiratory tract, about 20–43% patients also present with extrapulmonary manifestations such as coagulation disorders with thrombotic angiopathy. Case presentation: In our institution, a patient presented to the emergency department with acute abdominal pain which was caused by portal vein thrombosis. As a COVID-19 nasopharyngeal antigen swab few days earlier was negative, we performed several tests to find out its etiology. After all tests were inconclusive and the patient suffered flu-like symptoms 2 weeks before, we repeated COVID-19 molecular testing and received a positive test result. The patient was treated symptomatically and received therapeutic anticoagulation. Conclusion: A COVID-19 infection can also be present without typical pulmonary symptoms. In patients with severe abdominal pain and new diagnosed portal vein thrombosis, it is important to think of a COVID-19 infection. Also, the reliability of antigen nasopharyngeal swab should be considered critically, especially if performed wrongly. We recommended to perform molecular tests when in doubt. After the diagnosis of portal vein thrombosis, immediate anticoagulation is recommended to reduce the risk of further complications like intestinal infarction. [ABSTRACT FROM AUTHOR]

Objective: To describe the technique and outcomes of mesenteric access under ultrasound guidance to perform portal vein recanalization–transjugular intrahepatic portosystemic shunt (PVR-TIPS). Methods: Four patients (3 male: 1 female, mean age: 46.2 years; range 38–64 years) with portal vein thrombosis (PVT) and cavernous transformation were eligible for PVR-TIPS. Due to inaccessible splenic vein (one patient with history of splenectomy and 3 patients with unavailable splenic vein during the procedure), noninvasive direct puncture of superior (n = 3) and inferior (n = 1) mesenteric vein was conducted under ultrasound guidance to obtain access for PVR-TIPS. Results: Trans-mesenteric access and PVR-TIPS were successful in all patients at first attempt. No immediate complication was observed following the procedures. Follow-up imaging with computed tomography (CT) scan and Doppler ultrasound revealed patent TIPS and portal venous vasculature in all patients. Conclusion: Percutaneous noninvasive transmesenteric access is a feasible approach for PVR-TIPS in patients with inaccessible splenic veins. Level of evidence IV : This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. [ABSTRACT FROM AUTHOR]

Portal vein thrombosis is caused by various diseases, including liver cirrhosis, cancer, abdominal infection, and myeloproliferative disorders. Essential thrombocythemia is one of the myeloproliferative disorders in which the bone marrow produces excessive amount of platelets and can be accompanied by various thrombotic diseases; however, essential thrombocythemia with limited cutaneous systemic sclerosis has not been reported yet. We herein report a case of extensive portal vein thrombosis due to essential thrombocythemia with limited cutaneous systemic sclerosis. A 49-year-old woman was referred to our hospital due to liver dysfunction. Extended portal vein thrombosis, splenomegaly, and thrombocytosis were founded. The examination of Janus kinase 2 V617F mutation in the bone marrow was positive. These findings resulted in the diagnosis of portal vein thrombosis due to essential thrombocythemia. Furthermore, Raynaud's phenomenon, finger's sclerosis, and positive anti-centromere antibody led to limited cutaneous systemic sclerosis. To further analyze the causal relationship between essential thrombocythemia and limited cutaneous systemic sclerosis, platelet-derived growth factor was examined. High level of serum platelet-derived growth factor, possibly caused by high platelet count due to essential thrombocythemia, was observed. As platelet-derived growth factor has been reportedly associated with the occurrence of systemic sclerosis, the present case indicates the possible causal link between essential thrombocythemia and limited cutaneous systemic sclerosis through high platelet-derived growth factor. [ABSTRACT FROM AUTHOR]

Pancreatic pseudocyst and portal vein thrombosis are common conditions resulting from acute and chronic pancreatitis. However, pancreatic pseudocyst-portal vein fistula (PPVF) is a rare and life-threatening complication. In PPVF patients, drainage or operative therapy is necessary under certain conditions, including communication between the pseudocyst and pancreatic duct, pancreatic duct stricture, pancreatic duct stone, and infection that is difficult to control with antibiotics. We describe the case of a 78-year-old woman who presented with an infected pancreatic pseudocyst invading the portal venous system with obstruction due to thromboembolization. Conservative therapy with antibiotics was insufficient. We, therefore, performed endoscopic ultrasound-guided cyst-drainage (EUS-CD). During EUS-CD, PPVF and pseudocyst-pancreatic duct fistula were confirmed by contrast medium injection. Despite the presence of the pseudocyst-pancreatic duct fistula, the pancreatic duct was not visualized in the pancreatic head, suggesting stricture in the main pancreatic duct. We, therefore, performed endoscopic retrograde pancreatography, which revealed pancreatic stone in the main pancreatic duct. Then, we added a 7-Fr pancreatic stent. She was discharged after 89 days of hospitalization. We reviewed the literature on the management of PPVF formation, and EUS-CD is considered to be a good treatment option for PPVF patients without portal vein patency. [ABSTRACT FROM AUTHOR]

Background: There have been no reports on the effectiveness of the administration of antithrombin III (AT III) for post-transplant portal vein thrombosis (PVT). We herein report a case of post-transplant PVT that was resolved by AT III treatment after living donor liver transplantation (LDLT). Case presentation: The patient was a 57-year-old man who had been diagnosed with decompensate liver cirrhosis by hepatitis C virus infection. He presented with repeated hepatic coma and refractory ascites. Computed tomography (CT) revealed PVT of Yerdel classification grade II before LDLT. He underwent ABO-identical LDLT using a right lobe graft. A liver function test revealed elevated liver enzyme levels on post-operative day (POD) 14. The CT examination on POD 15 revealed PVT in the left side of the main portal vein at the side of left gastric vein ligation. AT III treatment from POD 15 to POD 24 was performed. Magnetic resonance imaging revealed that the PVT had decreased 10% on POD 27. Furthermore, AT III treatment from POD 28 to POD 32 was performed. The CT examination demonstrated the disappearance of PVT on POD 69 and thereafter, he had no recurrence of PVT on 10 post-operative month (POM). Conclusions: The present case suggests that the administration of AT III is safe and suitable for the treatment of post-transplant PVT. [ABSTRACT FROM AUTHOR]

Purpose: To report venous thrombosis and associated perfusion defect in amebic liver abscess (ALA) using MDCT. Method: MDCT images of 62 patients with ALA were reviewed for venous thrombosis and associated perfusion abnormalities. Result: The study found 43 (69%) patients with venous thrombosis: portal vein thrombosis (PVT) occurred in 39, hepatic vein thrombosis (HVT) in 37 and inferior vena cava (IVC) thrombosis in 4. Combined PVT and HVT occurred in 33 (77%) patients. The portal vein thrombi remained localized in subsegmental branches in 25 patients and extended to segmental branches in 14. The hepatic vein thrombi were confined to peripheral branches in 18 patients; they progressed to the main trunk in 19 and to the IVC in 4. A wedge-shaped hypoattenuating zone suggesting ischemia was identified in 33 (77%) patients in portal phase: 31 had combined PVT and HVT, 2 had HVT alone, but none had PVT alone. It occurred significantly more often with combined PVT and HVT than HVT alone (p = 0.05). Arterial phase enhancement occurred in 2 of 13 patients with multiphasic CT. All patients were symptomatic despite medical therapy and therefore required percutaneous drainage. About half of the patients were identified with ruptured abscesses. Segmental atrophy was observed in seven of nine patients who underwent follow-up CT. Conclusion: Combined PVT and HVT commonly occur with ALA and often manifests as segmental hypoperfusion in portal venous phase, indicating ischemia. The detection of such events by CT may be indicative of severe disease that requires aggressive management involving percutaneous drainage. [ABSTRACT FROM AUTHOR]