Pre-Transplant Management of Portal Vein Thrombosis

[Dr. Zach Berman]
Building upon that, most of our patients are going to get transplanted immediately and they might have a bunch of other issues going on medically that might need to be addressed. I think the first one I want to tackle is portal vein thrombus, and we're still not in the cancer space. We'll get to the cancer space in a second.

[Dr. John Seal]
Got it.

[Dr. Zach Berman]
But portal vein thrombus, bland thrombus, just from portal hypertension, from a surgical perspective, how much is too much?

[Dr. John Seal]
We try to be as creative as possible. I think it certainly fits into several different factors coming together. We're a lot less ambitious if the BMI is 50, which is technically doing that bypass or getting that vein open and having a successful recovery period goes down tremendously. The weight and the body habitus plays in quite a lot. Most of the time, so our approach at our center is we always start with thrombectomy, intraoperative thrombectomy. If that clot is contained just to the portal vein, then most of the time-- and it looks like it isn't too chronic and organized, the calcified portal vein clot is no fun for anyone. If it's relatively fresh clot, then we'll try to do a thrombectomy. If not, we can look at bypass options. Probably the most reliable and best outcomes are with a bypass from the superior mesenteric vein where we take cadaveric vein and we make a new portal vein.

Once you get outside of those two options, now we're looking at inflow options that have much poorer outcomes. If there's a lot of collateralization between the splenic vessels and the renal vessels, typically on the left side, then you can take the left renal vein and put a conduit and bring that up for portal inflow. We've done that a couple of times. That also can be a pretty tricky operation if they had SPP or any scarring. All these options are really, you don't want to go into it with that being plan A.

[Dr. Zach Berman]
Plan A is usually you guys with anticoagulation. At least in my experience, that's how it is. How do you determine whether someone's an anticoagulation candidate with varices and other bleeding risks, thrombocytopenia, et cetera?

[Dr. Heather Patton]
I'll say, because I'm a little older than you, this has definitely changed over the course of my practice. I think we used to have a lot of fear about anticoagulating this patient population. In fact, what the data have shown, as you understand, I know, the presence of a portal vein clot is actually increasing the severity of portal hypertension. With that, you may have enlarging higher risk varices that are more likely to bleed. If you identify a clot before it's recalcitrant calcified with extensive cavernous transformation, then you actually can reduce the risk of variceal bleeding by anticoagulating.

I think most people would do an endoscopy before initiating anticoagulation. Then, the other issue is sorting out what to use to anticoagulate these patients. I think the safest is often low molecular weight heparin. The DOACs are a little bit tricky, depending on the severity of liver disease. Warfarin can be complicated because we don't know necessarily where to aim the INR target.

[Dr. Stephen Young]
Yes, I think the other thing is we don't have great data yet for the DOACs and how safe they are to use in cirrhotics. It seems to be that they're pretty safe. The other thing that we want to consider is their transplant candidacy. If they're on a DOAC and they get called in for transplant, how easy is it going to be to reverse that? One is the ease of getting the medication to the cost. The reversal agents for some of them are very expensive if they're available.

Our practice is typically to use warfarin if they're listed for transplant. That way we know that they're easily reversible if they get called in for transplant because the timing of that is unknown. Low-molecular-weight heparin is another option because that's also easily reversible. A lot of it will depend on their transplant candidacy. I agree. We definitely would want to scope them before, make sure they don't have varices, band them ideally before sorting them on anticoagulation.

[Dr. Zach Berman]
How long would you give anticoagulation a shot before you start thinking of interventions to help? Because occasionally I find ourselves doing some intervention like portal vein recanalization in order to make the transplant easier if we can get the vein open before transplant, like a TIPS portal vein recanalization. What's your guys' experience with when we think about doing that?

[Dr. Stephen Young]
Yes, that's a tough question. I think that's when we get into our multidisciplinary conferences and we talk with interventional radiology, with transplant surgery, with hepatology, want to know how easy is this going to be to be accomplished? Is this going to be an easy interventional radiology procedure? Is it going to be time-intensive, risky for the patient? Is it really going to benefit them? We've done it a few times and the ones that I've personally seen have been successful. It's definitely something that we would talk about with our whole team and not just one person saying, let's do this and go forward with it.

[Dr. Zach Berman]
Would it be three months, six months after anticoagulation, or?

[Dr. Stephen Young]
I've seen them do it even before they're on anticoagulation and then put them on anticoagulation after. I don't know if there's enough data to say what's the right answer or not.

[Dr. John Seal]
That's the big issue, is we don't actually know the answer to this question. We got to operate in that space of what do we think is safe for the patient. We certainly think about-- so preemptive TIPS, I think, is a really interesting topic, and that's emerging. We don't have great data, but I know there's a lot of centers doing it, especially like a relatively small caliber TIPS bypass just to decompress that and you get better flow and that maybe even in combination is going to help with these partial portal vein clots.

We've had a couple of pretty aggressive approaches where we knew we needed to get the portal vein open to make them a good candidate and they've done thrombectomies and the transplanting approach and opened things up. The only thing I would say is the one that has caused me a good deal of headaches-- Talk to your surgeons, your transplant surgeons, before we start TIPS'ing them because if you park that portal vein stent under the pancreas in a cirrhotic patient, that is a treacherous thing. Even though the portal vein is technically open, that is pretty treacherous to try to reconstruct around and so that's one thought that I have about it.

[Dr. Zach Berman]
Then also, from a technical perspective, at least the transplant surgeons I've worked with said the other end on the hepatic vein side, not going into the right atrium can be tricky too.

[Dr. John Seal]
Yes, please don't. Yes, we don't like to get into the chest. We leave that to our cardiac colleagues. I've only had to do that one time where we had to open the pericardium and put a clamp up high, but that's a headache. What this comes down to is having good relationships with the providers in your network and the ones that you work with so that you know to make that phone call ahead of time and you know how it's done. We get into tough situations when people get IR therapies in places who aren't familiar with transplant and don't know to avoid these sorts of things. It's great to get that out there.

[Dr. Stephen Young]
I think the other thing to bring up too is taking into consideration their liver function. If they have a high MELD score and you go in and put a TIPS in, you have a high chance of making them sicker and potentially ineligible for transplant if they get too sick or things like that. Not always putting TIPS in on somebody who's really sick. You could potentially do more harm than good.