- Email: [email protected]
Efficacy of Transjugular Intrahepatic Portosystemic Shunt to Prevent Total Portal Vein Thrombosis in Cirrhotic Patients Awaiting for Liver Transplantation
Efficacy of Transjugular Intrahepatic Portosystemic Shunt to Prevent Total Portal Vein Thrombosis in Cirrhotic Patients Awaiting for Liver Transplantation D. D’Avola, J.I. Bilbao, G. Zozaya, F. Pardo, F. Rotellar, M. Iñarrairaegui, J. Quiroga, B. Sangro, and J.I. Herrero ABSTRACT Introduction. Complete portal vein thrombosis (PVT) may complicate orthotopic liver transplantation (OLT), increasing its technical difficulty and the transfusion requirements and as well as affecting survival in some cases. Transjugular intrahepatic portosystemic shunt (TIPS) prevents total portal vein occlusion in patients with partial PVT. Objective. We aimed to assess the efficacy and safety of TIPS to prevent total portal vein occlusion among patients listed for OLT. Patients and methods. We analyzed the clinical records of 15 consecutive patients with partial PVT who underwent TIPS before OLT. The control group consisted of 8 transplanted patients without TIPS but partial PVT diagnosed before OLT. Portal vein patency at surgery, ischemia time, and transfusion requirements during OLT, and survival thereafter were compared between both groups. The main complications were also compared: mortality after TIPS (from TIPS placement to OLT), intraoperative technical complications, and technical complications during the 6 months after OLT. Results. Clinical characteristics at the time of OLT were similar between the groups. No relevant complications were observed after TIPS; all patients underwent transplantation. One- and 5-year actuarial survival rates were similar in both groups (92% and 85% in TIPS-group versus 100 and 75% in the control group, respectively). No differences in transfusion requirement, duration of ischemia, and frequency of technical complications during and after OLT were observed between the groups. The portal vein was patent at surgery in all TIPS patients and 4 of 8 (50%) in the control group (P ⫽ .008). Conclusion.
TIPS may prevent PVT in liver transplantation candidates with partial PVT.
ortal vein thrombosis (PVT), a common complication of end-stage liver disease, shows a 5% to 26% prevalence among patients awaiting orthotopic liver transplantation (OLT).1– 4 Partial thrombosis, which is more frequent, may progress to total thrombosis.3,5,6 Total PVT could complicates the surgical procedure and increases morbidity and mortality after OLT.7,8 To prevent total occlusion of the portal vein and prevent thrombus extension to the other splanchic vessels, some investigations have suggested anticoagulation therapy.3,9,10 However, the risk of bleeding in patients with portal hypertension limits its use. Moreover, 10% of patients experience extension of the thrombus despite anticoagulation therapy.3,9 A transjugular intrahepatic portosystemic shunt (TIPS) might prevent total portal
P
vein occlusion in patients with partial PVT.11,12–14 However, the largest series reported shows a 20% to 38% frequency of TIPS dysfunction or thrombosis.11,15,16 Moreover, TIPS is not a risk-free procedure; its feasibility is limited in patients with poor liver function or in the
From the Liver Unit and CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas) (D.D., M.I., J.Q., B.S., J.I.H.), the Radiology Department (J.I.B.), and the Hepato-Biliopancreatic Surgery (G.Z., F.P., F.R.), Clinica Universidad de Navarra, Pamplona, Spain. Address reprint requests to Delia D’Avola, Unidad Hepatología, Clinica Universidad de Navarra, Av Pio XII 36. 31008, Spain. E-mail: [email protected]
© 2012 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/–see front matter http://dx.doi.org/10.1016/j.transproceed.2012.09.050
Transplantation Proceedings, 44, 2603–2605 (2012)
2603
2604
presence of hepatocellular carcinoma.17 Finally, there is no agreement about whether the presence of TIPS complicates OLT procedure. Indeed, TIPS misplacement is a wellknown condition that increases the technical difficulty of OLT.18 –21 This report sought to assess the results of TIPS to prevent total portal vein occlusion in patients with partial PVT awaiting OLT. MATERIALS AND METHODS Study Design We retrospectively analyzed the clinical records of consecutive liver transplantation candidates at a single center between 1995 and 2009. Patients with partial PVT who underwent TIPS before OLT constituted the study group (TIPS group). The control cohort consisted of all subjects in the same period who were diagnosed with partial PVT before OLT but not undergoing TIPS. Among the control group, the decision to perform a TIPS was based on medical criteria: presence of hepatocellular carcinoma, recurrent encephalopathy, or poor liver function. We examined demographic and clinical data including age, gender, etiology of liver disease, liver function, and liver imaging (ultrasound and Magnetic resonance imaging or computed tomography if available) before TIPS and before inclusion on the waiting list. We also recorded waiting list time and interval between TIPS and OLT. Child-Pugh and model for end-stage liver disease (MELD) scores were used to assess liver function at the time of OLT. Portal vein patency at surgery was considered to be the main outcome in addition to mortality after TIPS (from TIPS placement to OLT), intraoperative technical complications, cold ischemia time, and transfusion requirements during OLT. Survival after OLT and occurrence of biliary leakage or strictures, PVT or stenosis and of inferior vena cava anastomotic dysfunction were also compared over the 6 months after OLT.
D’AVOLA, BILBAO, ZOZAYA ET AL Table 1. Baseline Characteristics at Liver Transplantation Between Groups TIPS Group n ⫽ 15
Age, years Etiology of liver cirrhosis Alcohol/Virus/Other Hepatocellular carcinoma Bilirubin, mg/dL INR Child-Pugh score MELD score Type of portal thrombosis Branches Main trunk Both Waiting list time, days
Control Group n⫽8
P
67 (17)
ns
47%/47%/6% 7% 3.8 (2.6) 1.4 (0.3) 8 (3) 14 (4)
25%/50%/25% 37% 2.6 (2.5) 1.3 (0.4) 8 (3) 15 (6)
ns ns ns ns ns ns ns
26% (n ⫽ 4) 54% (n ⫽ 8) 20% (n ⫽ 3) 185 (200)
25% (n ⫽ 2) 75% (n ⫽ 6) 0 213 (228)
60 (8)
ns
Values are expressed as median (interquartile range), unless specified. Abbreviations: TIPS, transjugular intrahepatic postosystemic shunt; INR, international normalized ratio; MELD, model for end-stage liver disease.
No relevant complications were observed after TIPS; all patients were transplanted (Table 2). TIPS thrombosis occurred in 3 cases, requiring a second intervention to obtain recanalization. No differences in transfusion requirements, durations of ischemia, and frequencies of technical complications during and after OLT were observed between the groups (Table 2). At the time of surgery, the portal vein was patent in all TIPS patients, whereas total thrombosis was observed among 4 of 8 (50%) subjects without TIPS (P ⫽ .008; Table 2). Posttransplantation survival rates in both groups were similar (Table 2). DISCUSSION
Statistical Analysis Mann Whitney U and chi-squared tests were used to compare continuous and categorical variables. Survival rates expressed by the Kaplan-Meier method, were compared with the log-rank test using SPSS version 15.0 software (SPSS Inc. Headquarters, Chicago, Ill) for the statistical analysis.
RESULTS
The TIPS and control groups included 15 and 8 cirrhotic patients, respectively. Among the TIPS group, the indications for the procedure were: prevention of total PVT before transplantation (n ⫽ 8; 54%) secondary prophylaxis of refractory gastrointestinal bleeding (n ⫽ 6; 40%), or refractory ascitis (n ⫽ 1, 6%). Pretransplantation characteristics of both groups are shown in Table 1. Child-Pugh and MELD scores at the time of TIPS placement were 8 (interquartile range [IQR] 2.5) and 12 (IQR 5.5), respectively. The median IQR interval between TIPS and OLT was 398 (568) days. Waiting list time was similar in TIPS and control patients (Table 1). Demographic and clinical characteristics at the time of OLT were comparable between groups (Table 1). Main trunk partial occlusion was the most common presentation of portal thrombosis (Table 1). Indications for OLT were similar between the groups.
Total PVT can complicate OLT procedure,2,22,23 by increasing the technical difficulty of the portal anastomosis and increasing the risk of portal thrombosis after transplantation.24,25 Furthermore, the presence of portal thrombosis before OLT has been related to worse outcomes7 leading to decreased survival and increased morbidity.8,26 TIPS has been described to be a feasible procedure to prevent total portal vein occlusion among both noncirrhotic and cirrhotic patients with partial portal thrombosis14,13 as well as OLT candidates.27 In a recent report, Luca et al noted a 60% complete recanalization rate of partial or complete PVT and a partial improvement of thrombosis in 30% of cases after TIPS placement.15 Extension and severity of thrombosis, as well as the type of stent (bare or covered) predicted the probability of recanalization.15 Our series of patients with partial thrombosis who were treated with bare or covered stents showed 3 patients to require a second interventional procedure because of TIPS dysfunction or rethrombosis. We achieved our aim to have a patent portal vein in all TIPS patients although half of the control subjects displayed total portal occlusion at the time of surgery. Whether the presence of a TIPS complicates the transplantation procedure has been matter of debate. Retrospec-
PORTAL VEIN THROMBOSIS
2605
Table 2. Outcomes Among the Two Groups TIPS Group n ⫽ 15
TIPS mortality Survival rate 1-year 5-year Cold ischemia time, minutes* Portal vein patency at OLT Intraoperative blood cell transfusion, units* Technical complication at 6 months: Biliary leakage/strictures Cava vein stenosis Portal thrombosis/stenosis
Control Group n⫽8
P
NA
—
92% 85% 335 (118) 100% 4 (3)
100% 75% 329 (217) 50% 3 (5)
ns ns .008 ns
20% (n ⫽ 3)
50% (n ⫽ 4)
ns
1 1 1
3 0 1
0%
Abbreviations: TIPS, transjugular intrahepatic portosystemic shunt; OLT, orthotopic liver transplantation. *Median interquartile range.
tive series have shown contradictory results in terms of operative time or mortality and morbidity after OLT.18 –20 The main potential issue with TIPS in OLT is its misplacement or migration that may prolong the anhepatic phase of the procedure.21 In our series, we did not observe any instance of stent migration, although it has been reported in 17% to 27% of cases.20,21 This risk should be considered before performing a TIPS in an OLT candidate. The findings of this work suggested that TIPS was a safe procedure for selected cirrhotic patients with partial PVT. TIPS placement was neither related to an increased morbidity or mortality after OLT nor to increased technical difficulty at the time of the surgery, although it was helpful to maintain the patency of the portal vein until OLT. REFERENCES 1. Llado L, Fabregat J, Castellote J, et al: Management of portal vein thrombosis in liver transplantation: influence on morbidity and mortality. Clin Transplant 21:716, 2007 2. Englesbe MJ, Kubus J, Muhammad W, et al: Portal vein thrombosis and survival in patients with cirrhosis. Liver Transpl 16:83, 2010 3. Francoz C, Belghiti J, Vilgrain V, et al: Splanchnic vein thrombosis in candidates for liver transplantation: usefulness of screening and anticoagulation. Gut 54:691, 2005 4. Gayowski TJ, Marino IR, Doyle HR, et al: A high incidence of native portal vein thrombosis in veterans undergoing liver transplantation. J Surg Res 60:333, 1996 5. Ravaioli M, Zanello M, Grazi GL, et al: Portal vein thrombosis and liver transplantation: evolution during 10 years of experience at the University of Bologna. Ann Surg 253:378, 2011 6. Manzanet G, Sanjuan F, Orbis P, et al: Liver transplantation in patients with portal vein thrombosis. Liver Transpl 7:125, 2001 7. Pereira AA, Bhattacharya R, Carithers R, et al: Clinical factors predicting readmission after orthotopic liver transplantation. Liver Transpl 18:1037, 2012
8. Englesbe MJ, Schaubel DE, Cai S, et al: Portal vein thrombosis and liver transplant survival benefit. Liver Transpl 16:999, 2010 9. Amitrano L, Guardascione MA, Menchise A, et al: Safety and efficacy of anticoagulation therapy with low molecular weight heparin for portal vein thrombosis in patients with liver cirrhosis. J Clin Gastroenterol 44:448, 2010 10. Senzolo M, Ferronato C, Burra P, et al: Anticoagulation for portal vein thrombosis in cirrhotic patients should be always considered. Intern Emerg Med 4:161, 2009 (author reply, 163) 11. Han G, Qi X, He C, et al: Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosis. J Hepatol 54:78, 2011 12. Perarnau JM, Baju A, D’Alteroche L, et al: Feasibility and long-term evolution of TIPS in cirrhotic patients with portal thrombosis. Eur J Gastroenterol Hepatol 22:1093, 2010 13. Bilbao JI, Longo JM, Rousseau H, et al: Transjugular intrahepatic portocaval shunt after thrombus disruption in partially thrombosed portal veins. Cardiovasc Intervent Radiol 17:106, 1994 14. Bilbao JI, Elorz M, Vivas I, et al: Transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of venous symptomatic chronic portal thrombosis in non-cirrhotic patients. Cardiovasc Intervent Radiol 27:474, 2004 15. Luca A, Miraglia R, Caruso S, et al: Short- and long-term effects of the transjugular intrahepatic portosystemic shunt on portal vein thrombosis in patients with cirrhosis. Gut; 60:846, 2011 16. Senzolo M, Burra P, Patch D, et al: Tips for portal vein thrombosis (pvt) in cirrhosis: not only unblocking a pipe. J Hepatol 55:945, 2011 (author reply 947) 17. Boyer TD, Haskal ZJ: The Role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: update 2009. Hepatology 51:306, 2010 18. Goldberg MS, Weppler D, Khan FA, et al: Does transjugular intrahepatic portosystemic shunting facilitate or complicate liver transplantation? Transplant Proc 29:557, 1997 19. Moreno A, Meneu JC, Moreno E, et al: Liver transplantation and transjugular intrahepatic portosystemic shunt. Transplant Proc 35:1869, 2003 20. Tripathi D, Therapondos G, Redhead DN, et al: Transjugular intrahepatic portosystemic stent shunt and its effects on orthotopic liver transplantation. Eur J Gastroenterol Hepatol 14:827, 2002 21. Guerrini GP, Pleguezuelo M, Maimone S, et al: Impact of tips preliver transplantation for the outcome posttransplantation. Am J Transplant 9:192, 2009 22. Yerdel MA, Gunson B, Mirza D, et al: Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation 69:1873, 2000 23. Suarez Artacho G, Barrera Pulido L, Alamo Martinez JM, et al: Outcomes of liver transplantation in candidates with portal vein thrombosis. Transplant Proc 42:3156, 2010 24. Paskonis M, Jurgaitis J, Mehrabi A, et al: Surgical strategies for liver transplantation in the case of portal vein thrombosis– current role of cavoportal hemitransposition and renoportal anastomosis. Clin Transplant 20:551, 2006 25. Selvaggi G, Weppler D, Nishida S, et al: Ten-year experience in porto- caval hemitransposition for liver transplantation in the presence of portal vein thrombosis. Am J Transplant 7:454, 2007 26. Francoz C, Valla D, Durand F: Portal vein thrombosis, cirrhosis, and liver transplantation. J Hepatol 57:203, 2012 27. Bauer J, Johnson S, Durham J, et al: The role of TIPS for portal vein patency in liver transplant patients with portal vein thrombosis. Liver Transpl 12:1544, 2006
TIPS may prevent PVT in liver transplantation candidates with partial PVT.
ortal vein thrombosis (PVT), a common complication of end-stage liver disease, shows a 5% to 26% prevalence among patients awaiting orthotopic liver transplantation (OLT).1– 4 Partial thrombosis, which is more frequent, may progress to total thrombosis.3,5,6 Total PVT could complicates the surgical procedure and increases morbidity and mortality after OLT.7,8 To prevent total occlusion of the portal vein and prevent thrombus extension to the other splanchic vessels, some investigations have suggested anticoagulation therapy.3,9,10 However, the risk of bleeding in patients with portal hypertension limits its use. Moreover, 10% of patients experience extension of the thrombus despite anticoagulation therapy.3,9 A transjugular intrahepatic portosystemic shunt (TIPS) might prevent total portal
P
vein occlusion in patients with partial PVT.11,12–14 However, the largest series reported shows a 20% to 38% frequency of TIPS dysfunction or thrombosis.11,15,16 Moreover, TIPS is not a risk-free procedure; its feasibility is limited in patients with poor liver function or in the
From the Liver Unit and CIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas) (D.D., M.I., J.Q., B.S., J.I.H.), the Radiology Department (J.I.B.), and the Hepato-Biliopancreatic Surgery (G.Z., F.P., F.R.), Clinica Universidad de Navarra, Pamplona, Spain. Address reprint requests to Delia D’Avola, Unidad Hepatología, Clinica Universidad de Navarra, Av Pio XII 36. 31008, Spain. E-mail: [email protected]
© 2012 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/–see front matter http://dx.doi.org/10.1016/j.transproceed.2012.09.050
Transplantation Proceedings, 44, 2603–2605 (2012)
2603
2604
presence of hepatocellular carcinoma.17 Finally, there is no agreement about whether the presence of TIPS complicates OLT procedure. Indeed, TIPS misplacement is a wellknown condition that increases the technical difficulty of OLT.18 –21 This report sought to assess the results of TIPS to prevent total portal vein occlusion in patients with partial PVT awaiting OLT. MATERIALS AND METHODS Study Design We retrospectively analyzed the clinical records of consecutive liver transplantation candidates at a single center between 1995 and 2009. Patients with partial PVT who underwent TIPS before OLT constituted the study group (TIPS group). The control cohort consisted of all subjects in the same period who were diagnosed with partial PVT before OLT but not undergoing TIPS. Among the control group, the decision to perform a TIPS was based on medical criteria: presence of hepatocellular carcinoma, recurrent encephalopathy, or poor liver function. We examined demographic and clinical data including age, gender, etiology of liver disease, liver function, and liver imaging (ultrasound and Magnetic resonance imaging or computed tomography if available) before TIPS and before inclusion on the waiting list. We also recorded waiting list time and interval between TIPS and OLT. Child-Pugh and model for end-stage liver disease (MELD) scores were used to assess liver function at the time of OLT. Portal vein patency at surgery was considered to be the main outcome in addition to mortality after TIPS (from TIPS placement to OLT), intraoperative technical complications, cold ischemia time, and transfusion requirements during OLT. Survival after OLT and occurrence of biliary leakage or strictures, PVT or stenosis and of inferior vena cava anastomotic dysfunction were also compared over the 6 months after OLT.
D’AVOLA, BILBAO, ZOZAYA ET AL Table 1. Baseline Characteristics at Liver Transplantation Between Groups TIPS Group n ⫽ 15
Age, years Etiology of liver cirrhosis Alcohol/Virus/Other Hepatocellular carcinoma Bilirubin, mg/dL INR Child-Pugh score MELD score Type of portal thrombosis Branches Main trunk Both Waiting list time, days
Control Group n⫽8
P
67 (17)
ns
47%/47%/6% 7% 3.8 (2.6) 1.4 (0.3) 8 (3) 14 (4)
25%/50%/25% 37% 2.6 (2.5) 1.3 (0.4) 8 (3) 15 (6)
ns ns ns ns ns ns ns
26% (n ⫽ 4) 54% (n ⫽ 8) 20% (n ⫽ 3) 185 (200)
25% (n ⫽ 2) 75% (n ⫽ 6) 0 213 (228)
60 (8)
ns
Values are expressed as median (interquartile range), unless specified. Abbreviations: TIPS, transjugular intrahepatic postosystemic shunt; INR, international normalized ratio; MELD, model for end-stage liver disease.
No relevant complications were observed after TIPS; all patients were transplanted (Table 2). TIPS thrombosis occurred in 3 cases, requiring a second intervention to obtain recanalization. No differences in transfusion requirements, durations of ischemia, and frequencies of technical complications during and after OLT were observed between the groups (Table 2). At the time of surgery, the portal vein was patent in all TIPS patients, whereas total thrombosis was observed among 4 of 8 (50%) subjects without TIPS (P ⫽ .008; Table 2). Posttransplantation survival rates in both groups were similar (Table 2). DISCUSSION
Statistical Analysis Mann Whitney U and chi-squared tests were used to compare continuous and categorical variables. Survival rates expressed by the Kaplan-Meier method, were compared with the log-rank test using SPSS version 15.0 software (SPSS Inc. Headquarters, Chicago, Ill) for the statistical analysis.
RESULTS
The TIPS and control groups included 15 and 8 cirrhotic patients, respectively. Among the TIPS group, the indications for the procedure were: prevention of total PVT before transplantation (n ⫽ 8; 54%) secondary prophylaxis of refractory gastrointestinal bleeding (n ⫽ 6; 40%), or refractory ascitis (n ⫽ 1, 6%). Pretransplantation characteristics of both groups are shown in Table 1. Child-Pugh and MELD scores at the time of TIPS placement were 8 (interquartile range [IQR] 2.5) and 12 (IQR 5.5), respectively. The median IQR interval between TIPS and OLT was 398 (568) days. Waiting list time was similar in TIPS and control patients (Table 1). Demographic and clinical characteristics at the time of OLT were comparable between groups (Table 1). Main trunk partial occlusion was the most common presentation of portal thrombosis (Table 1). Indications for OLT were similar between the groups.
Total PVT can complicate OLT procedure,2,22,23 by increasing the technical difficulty of the portal anastomosis and increasing the risk of portal thrombosis after transplantation.24,25 Furthermore, the presence of portal thrombosis before OLT has been related to worse outcomes7 leading to decreased survival and increased morbidity.8,26 TIPS has been described to be a feasible procedure to prevent total portal vein occlusion among both noncirrhotic and cirrhotic patients with partial portal thrombosis14,13 as well as OLT candidates.27 In a recent report, Luca et al noted a 60% complete recanalization rate of partial or complete PVT and a partial improvement of thrombosis in 30% of cases after TIPS placement.15 Extension and severity of thrombosis, as well as the type of stent (bare or covered) predicted the probability of recanalization.15 Our series of patients with partial thrombosis who were treated with bare or covered stents showed 3 patients to require a second interventional procedure because of TIPS dysfunction or rethrombosis. We achieved our aim to have a patent portal vein in all TIPS patients although half of the control subjects displayed total portal occlusion at the time of surgery. Whether the presence of a TIPS complicates the transplantation procedure has been matter of debate. Retrospec-
PORTAL VEIN THROMBOSIS
2605
Table 2. Outcomes Among the Two Groups TIPS Group n ⫽ 15
TIPS mortality Survival rate 1-year 5-year Cold ischemia time, minutes* Portal vein patency at OLT Intraoperative blood cell transfusion, units* Technical complication at 6 months: Biliary leakage/strictures Cava vein stenosis Portal thrombosis/stenosis
Control Group n⫽8
P
NA
—
92% 85% 335 (118) 100% 4 (3)
100% 75% 329 (217) 50% 3 (5)
ns ns .008 ns
20% (n ⫽ 3)
50% (n ⫽ 4)
ns
1 1 1
3 0 1
0%
Abbreviations: TIPS, transjugular intrahepatic portosystemic shunt; OLT, orthotopic liver transplantation. *Median interquartile range.
tive series have shown contradictory results in terms of operative time or mortality and morbidity after OLT.18 –20 The main potential issue with TIPS in OLT is its misplacement or migration that may prolong the anhepatic phase of the procedure.21 In our series, we did not observe any instance of stent migration, although it has been reported in 17% to 27% of cases.20,21 This risk should be considered before performing a TIPS in an OLT candidate. The findings of this work suggested that TIPS was a safe procedure for selected cirrhotic patients with partial PVT. TIPS placement was neither related to an increased morbidity or mortality after OLT nor to increased technical difficulty at the time of the surgery, although it was helpful to maintain the patency of the portal vein until OLT. REFERENCES 1. Llado L, Fabregat J, Castellote J, et al: Management of portal vein thrombosis in liver transplantation: influence on morbidity and mortality. Clin Transplant 21:716, 2007 2. Englesbe MJ, Kubus J, Muhammad W, et al: Portal vein thrombosis and survival in patients with cirrhosis. Liver Transpl 16:83, 2010 3. Francoz C, Belghiti J, Vilgrain V, et al: Splanchnic vein thrombosis in candidates for liver transplantation: usefulness of screening and anticoagulation. Gut 54:691, 2005 4. Gayowski TJ, Marino IR, Doyle HR, et al: A high incidence of native portal vein thrombosis in veterans undergoing liver transplantation. J Surg Res 60:333, 1996 5. Ravaioli M, Zanello M, Grazi GL, et al: Portal vein thrombosis and liver transplantation: evolution during 10 years of experience at the University of Bologna. Ann Surg 253:378, 2011 6. Manzanet G, Sanjuan F, Orbis P, et al: Liver transplantation in patients with portal vein thrombosis. Liver Transpl 7:125, 2001 7. Pereira AA, Bhattacharya R, Carithers R, et al: Clinical factors predicting readmission after orthotopic liver transplantation. Liver Transpl 18:1037, 2012
8. Englesbe MJ, Schaubel DE, Cai S, et al: Portal vein thrombosis and liver transplant survival benefit. Liver Transpl 16:999, 2010 9. Amitrano L, Guardascione MA, Menchise A, et al: Safety and efficacy of anticoagulation therapy with low molecular weight heparin for portal vein thrombosis in patients with liver cirrhosis. J Clin Gastroenterol 44:448, 2010 10. Senzolo M, Ferronato C, Burra P, et al: Anticoagulation for portal vein thrombosis in cirrhotic patients should be always considered. Intern Emerg Med 4:161, 2009 (author reply, 163) 11. Han G, Qi X, He C, et al: Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosis. J Hepatol 54:78, 2011 12. Perarnau JM, Baju A, D’Alteroche L, et al: Feasibility and long-term evolution of TIPS in cirrhotic patients with portal thrombosis. Eur J Gastroenterol Hepatol 22:1093, 2010 13. Bilbao JI, Longo JM, Rousseau H, et al: Transjugular intrahepatic portocaval shunt after thrombus disruption in partially thrombosed portal veins. Cardiovasc Intervent Radiol 17:106, 1994 14. Bilbao JI, Elorz M, Vivas I, et al: Transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of venous symptomatic chronic portal thrombosis in non-cirrhotic patients. Cardiovasc Intervent Radiol 27:474, 2004 15. Luca A, Miraglia R, Caruso S, et al: Short- and long-term effects of the transjugular intrahepatic portosystemic shunt on portal vein thrombosis in patients with cirrhosis. Gut; 60:846, 2011 16. Senzolo M, Burra P, Patch D, et al: Tips for portal vein thrombosis (pvt) in cirrhosis: not only unblocking a pipe. J Hepatol 55:945, 2011 (author reply 947) 17. Boyer TD, Haskal ZJ: The Role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: update 2009. Hepatology 51:306, 2010 18. Goldberg MS, Weppler D, Khan FA, et al: Does transjugular intrahepatic portosystemic shunting facilitate or complicate liver transplantation? Transplant Proc 29:557, 1997 19. Moreno A, Meneu JC, Moreno E, et al: Liver transplantation and transjugular intrahepatic portosystemic shunt. Transplant Proc 35:1869, 2003 20. Tripathi D, Therapondos G, Redhead DN, et al: Transjugular intrahepatic portosystemic stent shunt and its effects on orthotopic liver transplantation. Eur J Gastroenterol Hepatol 14:827, 2002 21. Guerrini GP, Pleguezuelo M, Maimone S, et al: Impact of tips preliver transplantation for the outcome posttransplantation. Am J Transplant 9:192, 2009 22. Yerdel MA, Gunson B, Mirza D, et al: Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation 69:1873, 2000 23. Suarez Artacho G, Barrera Pulido L, Alamo Martinez JM, et al: Outcomes of liver transplantation in candidates with portal vein thrombosis. Transplant Proc 42:3156, 2010 24. Paskonis M, Jurgaitis J, Mehrabi A, et al: Surgical strategies for liver transplantation in the case of portal vein thrombosis– current role of cavoportal hemitransposition and renoportal anastomosis. Clin Transplant 20:551, 2006 25. Selvaggi G, Weppler D, Nishida S, et al: Ten-year experience in porto- caval hemitransposition for liver transplantation in the presence of portal vein thrombosis. Am J Transplant 7:454, 2007 26. Francoz C, Valla D, Durand F: Portal vein thrombosis, cirrhosis, and liver transplantation. J Hepatol 57:203, 2012 27. Bauer J, Johnson S, Durham J, et al: The role of TIPS for portal vein patency in liver transplant patients with portal vein thrombosis. Liver Transpl 12:1544, 2006