Portal vein thrombosis, cirrhosis, and liver transplantation
Portal vein thrombosis, cirrhosis, and liver transplantation
复制标题
DOI：
10.1016/j.jhep.2011.12.034
复制
发表时间：
2012-07-01
影响因子：
25.7
通讯作者：
Durand, Francois
中科院分区：
文献类型：
--
作者：
Francoz, Claire;Valla, Dominique;Durand, Francois
门静脉血栓形成在移植候选者中并不少见。部分血栓形成比完全血栓形成更常见。尽管在评价时进行了仔细筛选，但仍发现许多患者术前存在未识别的血栓形成。目的是再通门静脉，或者如果再通无法实现，则防止血栓延伸，以便内脏静脉可用作流入血管，以恢复同种异体移植物的生理血流。等待期间抗凝和经颈静脉肝内门体分流术（TIPS）是实现这些目标的两种选择。TIPS可使完全性门静脉血栓形成患者实现再通。然而，肝功能明显受损，这是大多数移植候选人的特征，可能是TIPS的禁忌症。重要的是，由于INR延长，给予维生素K拮抗剂会人为增加MELD评分。当门静脉和/或上级肠系膜静脉未达到通畅时，只能进行非解剖技术（肾门静脉吻合或腔门静脉半转位）。这些技术不能完全逆转门静脉高压，与较高的发病率和死亡率风险相关。包括肝脏和小肠在内的多脏器移植需要进行评估。在没有移植后可能持续存在的血栓前状态的情况下，没有证据表明移植前门静脉血栓形成证明移植后长期抗凝是合理的，前提是门静脉血流已经通过传统的端对端门静脉吻合术恢复。(C)2012年欧洲肝脏研究协会。Elsevier B. V.出版，保留所有权利。
Portal vein thrombosis is not uncommon in candidates for transplantation. Partial thrombosis is more common than complete thrombosis. Despite careful screening at evaluation, a number of patients are still found with previously unrecognized thrombosis per-operatively. The objective is to recanalize the portal vein or, if recanalization is not achievable, to prevent the extension of the thrombus so that a splanchnic vein can be used as the inflow vessel to restore physiological blood flow to the allograft. Anticoagulation during waiting time and transjugular intrahepatic portosystemic shunt (TIPS) are two options to achieve these goals. TIPS may achieve recanalization in patients with complete portal vein thrombosis. However, a marked impairment in liver function, which is a characteristic feature of most candidates for transplantation, may be a contraindication for TIPS. Importantly, the MELD score is artificially increased by the administration of vitamin K antagonists due to prolonged INR. When patency of the portal vein and/or superior mesenteric vein is not achieved, only non-anatomical techniques (renoportal anastomosis or cavoportal hemitransposition) can be performed. These techniques, which do not fully reverse portal hypertension, are associated with higher morbidity and mortality risks. Multivisceral transplantation including the liver and small bowel needs to be evaluated. In the absence of prothrombotic states that may persist after transplantation, there is no evidence that pre-transplant portal vein thrombosis justifies long term anticoagulation post-transplantation, provided portal flow has been restored through conventional end-to-end portal anastomosis. (C) 2012 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.