Percutaneous procedure gives alternative to anticoagulation for portal vein thrombosis

 

WASHINGTON – Catheter-directed clot lysis and thrombectomy with creation of a bypass shunt is a reasonable alternative to prolonged anticoagulation for treating patients with portal vein thrombosis (PVT) based on the accumulated reported experience since 1993 using this percutaneous treatment.

Use of a transjugular intrahepatic portosystemic shunt (TIPS) for treating portal vein thrombosis (PVT) “is feasible and effective in achieving a significant and sustainable reduction in clot burden with a low risk of major complications,” Nelson Valentin, MD, said at the annual Digestive Disease Week.^® “TIPS should be considered a viable treatment option for patients with PVT,” said Dr. Valentin, a gastroenterology fellow at Mount Sinai Beth Israel hospital in New York.

Mitchel L. Zoler/MDedge News

His systematic review of the literature identified 18 case series published during 1993-2016 that included a total of 439 patients who underwent TIPS. Analysis of the accumulated data showed that operators performed TIPS with technical success in 87% of these reported cases, achieved at least partial recanalization of portal outflow in 84% of patients, and produced complete recanalization in 74%. The average reported change in portal vein pressure was a reduction of 14.5 mm Hg, and the major adverse effect was hepatic encephalopathy, which occurred in a quarter of patients but generally resolved without sequelae. No patients died as a result of undergoing the procedure.

“There is sufficient evidence from these reports to at least consider TIPS as an adjunct to anticoagulation or perhaps as primary therapy,” especially for patients with PVT who have a contraindication for anticoagulation, Dr. Valentin said in an interview. Standard anticoagulation for PVT would today involve acute treatment with a low-molecular-weight heparin followed by oral anticoagulation for a total treatment time of at least 6 months and continued for a year or longer in some patients. A recently published review of reported experience using anticoagulation to treat PVT found a complete recanalization rate of 41% and a complete or partial rate of 66%, which suggests that TIPS is at least as effective, although Dr. Valentin cautioned that no reported study has directly compared the two alternative approaches. A study designed to make this direct comparison is warranted by the reported results using TIPS, Dr. Valentin said. And the experience with TIPS positions it as an option for patients who do not respond to anticoagulation or would prefer an alternative to prolonged anticoagulation.

One factor currently limiting use of TIPS, which is usually performed by an interventional radiologist, is that the procedure is technically demanding, with a limited number of operators with the expertise to perform it. If TIPS became more widely accepted as an option for treating PVT, then the pool of interventionalists experienced with performing the procedure would grow, Dr. Valentin noted.

mzoler@mdedge.com

On Twitter @mitchelzoler

SOURCE: Valentin N et al. Digestive Disease Week, Presentation 361.

 

WASHINGTON – Catheter-directed clot lysis and thrombectomy with creation of a bypass shunt is a reasonable alternative to prolonged anticoagulation for treating patients with portal vein thrombosis (PVT) based on the accumulated reported experience since 1993 using this percutaneous treatment.

Use of a transjugular intrahepatic portosystemic shunt (TIPS) for treating portal vein thrombosis (PVT) “is feasible and effective in achieving a significant and sustainable reduction in clot burden with a low risk of major complications,” Nelson Valentin, MD, said at the annual Digestive Disease Week.^® “TIPS should be considered a viable treatment option for patients with PVT,” said Dr. Valentin, a gastroenterology fellow at Mount Sinai Beth Israel hospital in New York.

Mitchel L. Zoler/MDedge News

His systematic review of the literature identified 18 case series published during 1993-2016 that included a total of 439 patients who underwent TIPS. Analysis of the accumulated data showed that operators performed TIPS with technical success in 87% of these reported cases, achieved at least partial recanalization of portal outflow in 84% of patients, and produced complete recanalization in 74%. The average reported change in portal vein pressure was a reduction of 14.5 mm Hg, and the major adverse effect was hepatic encephalopathy, which occurred in a quarter of patients but generally resolved without sequelae. No patients died as a result of undergoing the procedure.

“There is sufficient evidence from these reports to at least consider TIPS as an adjunct to anticoagulation or perhaps as primary therapy,” especially for patients with PVT who have a contraindication for anticoagulation, Dr. Valentin said in an interview. Standard anticoagulation for PVT would today involve acute treatment with a low-molecular-weight heparin followed by oral anticoagulation for a total treatment time of at least 6 months and continued for a year or longer in some patients. A recently published review of reported experience using anticoagulation to treat PVT found a complete recanalization rate of 41% and a complete or partial rate of 66%, which suggests that TIPS is at least as effective, although Dr. Valentin cautioned that no reported study has directly compared the two alternative approaches. A study designed to make this direct comparison is warranted by the reported results using TIPS, Dr. Valentin said. And the experience with TIPS positions it as an option for patients who do not respond to anticoagulation or would prefer an alternative to prolonged anticoagulation.

One factor currently limiting use of TIPS, which is usually performed by an interventional radiologist, is that the procedure is technically demanding, with a limited number of operators with the expertise to perform it. If TIPS became more widely accepted as an option for treating PVT, then the pool of interventionalists experienced with performing the procedure would grow, Dr. Valentin noted.

mzoler@mdedge.com

On Twitter @mitchelzoler

SOURCE: Valentin N et al. Digestive Disease Week, Presentation 361.

 

WASHINGTON – Catheter-directed clot lysis and thrombectomy with creation of a bypass shunt is a reasonable alternative to prolonged anticoagulation for treating patients with portal vein thrombosis (PVT) based on the accumulated reported experience since 1993 using this percutaneous treatment.

Use of a transjugular intrahepatic portosystemic shunt (TIPS) for treating portal vein thrombosis (PVT) “is feasible and effective in achieving a significant and sustainable reduction in clot burden with a low risk of major complications,” Nelson Valentin, MD, said at the annual Digestive Disease Week.^® “TIPS should be considered a viable treatment option for patients with PVT,” said Dr. Valentin, a gastroenterology fellow at Mount Sinai Beth Israel hospital in New York.

Mitchel L. Zoler/MDedge News

His systematic review of the literature identified 18 case series published during 1993-2016 that included a total of 439 patients who underwent TIPS. Analysis of the accumulated data showed that operators performed TIPS with technical success in 87% of these reported cases, achieved at least partial recanalization of portal outflow in 84% of patients, and produced complete recanalization in 74%. The average reported change in portal vein pressure was a reduction of 14.5 mm Hg, and the major adverse effect was hepatic encephalopathy, which occurred in a quarter of patients but generally resolved without sequelae. No patients died as a result of undergoing the procedure.

“There is sufficient evidence from these reports to at least consider TIPS as an adjunct to anticoagulation or perhaps as primary therapy,” especially for patients with PVT who have a contraindication for anticoagulation, Dr. Valentin said in an interview. Standard anticoagulation for PVT would today involve acute treatment with a low-molecular-weight heparin followed by oral anticoagulation for a total treatment time of at least 6 months and continued for a year or longer in some patients. A recently published review of reported experience using anticoagulation to treat PVT found a complete recanalization rate of 41% and a complete or partial rate of 66%, which suggests that TIPS is at least as effective, although Dr. Valentin cautioned that no reported study has directly compared the two alternative approaches. A study designed to make this direct comparison is warranted by the reported results using TIPS, Dr. Valentin said. And the experience with TIPS positions it as an option for patients who do not respond to anticoagulation or would prefer an alternative to prolonged anticoagulation.

One factor currently limiting use of TIPS, which is usually performed by an interventional radiologist, is that the procedure is technically demanding, with a limited number of operators with the expertise to perform it. If TIPS became more widely accepted as an option for treating PVT, then the pool of interventionalists experienced with performing the procedure would grow, Dr. Valentin noted.

mzoler@mdedge.com

On Twitter @mitchelzoler

SOURCE: Valentin N et al. Digestive Disease Week, Presentation 361.