Portal vein surgical treatment on non-tumoral portal vein thrombosis in liver transplantation: Systematic Review and Meta-Analysis

Lucas S. Nacif Leonardo Y. Zanini Rafael S. Pinheiro Daniel R. Waisberg Vinicius Rocha-Santos Wellington Andraus Flair J. Carrilho Luiz Carneiro-D'Albuquerque About the authors

Abstract

Non-tumoral portal vein thrombosis (PVT) is associated with higher morbidity and mortality in liver transplantation (LT). In this study, we aimed to evaluate the impact of PVT in LT outcomes and analyze the types of surgical techniques used for dealing with PVT during LT.

A systematic review was conducted in Cochrane, MEDLINE, and EMBASE databases, selecting articles from January 1990 to December 2019. The MESH-terms used were (“Portal Vein”[Mesh] AND “Thrombosis”[Mesh] NOT “Neoplasms”[Mesh]) AND (“Liver Transplantation”[Mesh]). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) recommendation was used, and meta-analysis was performed with Review Manager Version 5.3 software.

A total of 1,638 articles were initially found: 488 in PubMed, 289 in Cochrane Library, and 861 in EMBASE, from which 27 were eventually selected for the meta-analysis. Surgery time of LT in patients with PVT was longer than in patients without LT (p<0.0001). Intraoperative red blood cell (p<0.00001), fresh frozen plasma (p=0.01), and platelets (p=0.03) transfusions during LT were higher in patients with PVT. One-year (odds ratio [OR] 1.17; p=0.002) and 5-year (OR 1.12; p=0.01) patient survival after LT was worse in the PVT group. Total occlusive PVT presented higher mortality (OR 3.70; p=0.00009) and rethrombosis rates (OR 3.47 [1.18-10.21]; p=0.02). PVT Yerdel III/IV classification exhibited worse 1-year [2.04 (1.21-3.42); p=0.007] and 5-year [0.98 (0.59-1.62); p=0.93] patient survival. Thrombectomy with primary anastomosis was associated with better outcomes.

LT in patients with non-tumoral PVT demands more surgical time, needs more intraoperative transfusion, and presents worse 1- and 5-year patient survival. Total occlusive PVT and Yerdel III/IV PVT classification were associated with higher mortality. (PROSPERO, registration number: CRD42020132915).

Liver Transplantation; Portal Vein Thrombosis; Systematic Review; Portal Vein; Cirrhotic; Liver Disease


INTRODUCTION

Non-tumoral portal vein thrombosis (PVT) is a relevant condition in liver cirrhosis evolution, with an estimated incidence rate of 0.7 per 100,000 and prevalence ranging from 0.6-28% in cirrhotic patients (11. Nonami T, Yokoyama I, Iwatsuki S, Starzl TE. The incidence of portal vein thrombosis at liver transplantation. Hepatology. 1992;16(5):1195-8. https://doi.org/10.1002/hep.1840160515.
https://doi.org/10.1002/hep.1840160515...

2. Ponziani FR, Zocco MA, Garcovich M, D’Aversa F, Roccarina D, Gasbarrini A. What we should know about portal vein thrombosis in cirrhotic patients: a changing perspective. World J Gastroenterol. 2012;18(36):5014-20. https://doi.org/10.3748/wjg.v18.i36.5014.
https://doi.org/10.3748/wjg.v18.i36.5014...
-33. Violi F, Corazza GR, Caldwell SH, Perticone F, Gatta A, Angelico M, et al. Portal vein thrombosis relevance on liver cirrhosis: Italian Venous Thrombotic Events Registry. Intern Emerg Med. 2016;11(8):1059-66. https://doi.org/10.1007/s11739-016-1416-8.
https://doi.org/10.1007/s11739-016-1416-...
). It is well-established that patients with severe cirrhosis (Child-Pugh C Classification) have a high incidence of PVT (44. Lai Q, Spoletini G, Pinheiro RS, Melandro F, Guglielmo N, Lerut J. From portal to splanchnic venous thrombosis: What surgeons should bear in mind. World J Hepatol. 2014;6(8):549-58. https://doi.org/10.4254/wjh.v6.i8.549.
https://doi.org/10.4254/wjh.v6.i8.549...
).

PVT is defined as partial or complete obstruction of blood flow that occurs secondary to a thrombus in the portal vein, which results in the occlusion of the vessel lumen (11. Nonami T, Yokoyama I, Iwatsuki S, Starzl TE. The incidence of portal vein thrombosis at liver transplantation. Hepatology. 1992;16(5):1195-8. https://doi.org/10.1002/hep.1840160515.
https://doi.org/10.1002/hep.1840160515...

2. Ponziani FR, Zocco MA, Garcovich M, D’Aversa F, Roccarina D, Gasbarrini A. What we should know about portal vein thrombosis in cirrhotic patients: a changing perspective. World J Gastroenterol. 2012;18(36):5014-20. https://doi.org/10.3748/wjg.v18.i36.5014.
https://doi.org/10.3748/wjg.v18.i36.5014...
-33. Violi F, Corazza GR, Caldwell SH, Perticone F, Gatta A, Angelico M, et al. Portal vein thrombosis relevance on liver cirrhosis: Italian Venous Thrombotic Events Registry. Intern Emerg Med. 2016;11(8):1059-66. https://doi.org/10.1007/s11739-016-1416-8.
https://doi.org/10.1007/s11739-016-1416-...
). Despite this, the decreased portal flow velocity and the increased flow volume are considered independent risk factors in developing PVT (44. Lai Q, Spoletini G, Pinheiro RS, Melandro F, Guglielmo N, Lerut J. From portal to splanchnic venous thrombosis: What surgeons should bear in mind. World J Hepatol. 2014;6(8):549-58. https://doi.org/10.4254/wjh.v6.i8.549.
https://doi.org/10.4254/wjh.v6.i8.549...
). There are many classifications regarding the extent of involvement of the portal venous system, with the Yerdel classification being the most used one (55. Yerdel MA, Gunson B, Mirza D, Karayalçin K, Olliff S, Buckels J, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69(9):1873-81. https://doi.org/10.1097/00007890-200005150-00023.
https://doi.org/10.1097/00007890-2000051...
). It is paramount to promptly diagnose PVT, as this may lead to better outcomes and survival.

In the past, PVT in cirrhotic patients was considered a contraindication for liver transplantation (LT). Nevertheless, with the development of better diagnostic tools, medical therapy, and surgical techniques in the last decades, LT became a feasible therapeutic option even for patients with PVT (66. Tzakis A, Todo S, Stieber A, Starzl TE. Venous jump grafts for liver transplantation in patients with portal vein thrombosis. Transplantation. 1989;48(3):530-1. https://doi.org/10.1097/00007890-198909000-00040.
https://doi.org/10.1097/00007890-1989090...
). Based on the grade of PVT and severity of the cirrhosis, the decision to perform LT in these patients remains controversial.

Despite the modern advances in with the management of PVT, the outcome of LT in patients with PVT is still under debate, especially in the current era of organ shortage associated with a high model of end-stage liver disease (MELD) score of patients. The main objective of this study was to compare the outcomes of LT in patients with PVT and those without, focusing on the types of PVT surgical treatment, which include thrombectomy with primary anastomosis, interposition vein graft (physiological reconstruction), superior mesenteric vein (SMV) jump graft, interposition vein graft from a collateral vein (non-physiological reconstruction), renoportal anastomosis and cavoportal hemitransposition (CPH).

The present data may help validate whether the different types of portal vein (PV) reconstructions influence transplant outcomes in terms of survival and complications.

MATERIAL AND METHODS

Study identification and selection

A systematic review of the literature was performed for intraoperative management of PVT during LT. The Cochrane Library, EMBASE, and MEDLINE-PubMed databases were electronically searched from 1990 to December 2019. The MESH-terms used were (“Portal Vein”[Mesh] AND “Thrombosis”[Mesh] NOT “Neoplasms”[Mesh]) AND (“Liver Transplantation[Mesh]).

The terms and MESH-terms for PubMed database search were developed based on the PICO (patient, intervention, comparison, or control, outcome) structure. The results of the search terms forming the “P” (patients) group were merged with the results of the “I” (intervention) group with an “AND.” To exclude terms, they were merged with “NOT.”

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist were followed throughout this study (77. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. https://doi.org/10.1371/journal.pmed.1000097
https://doi.org/10.1371/journal.pmed.100...
,88. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100. https://doi.org/10.1371/journal.pmed.1000100
https://doi.org/10.1371/journal.pmed.100...
).

Two independent researchers (LSN and LYZ) evaluated the quality and selection of the studies. In the case of disagreement, the researchers held a consensus meeting to reach a final decision.

Inclusion and exclusion criteria

Within the research question of the PICO structure, the comparison of patients with non-tumoral PVT who underwent LT was defined as inclusion criteria. Only randomized controlled trials, nonrandomized controlled trials, or comparative clinical studies were included. All studies evaluated were written in English. Case series with less than six patients and studies reporting on tumoral thrombosis or Budd-Chiari syndrome were excluded.

Data synthesis and statistical analysis

Data were extracted from text, tables, and figures of the original published articles. The measures of effectiveness for each treatment were expressed in absolute numbers and respective frequencies, i.e., the absolute risk. For the meta-analysis, the data were synthesized using Review Manager Version 5.4 software provided by the Cochrane Collaboration (RevMan; The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). The results from the included papers were compared with the differences observed in absolute risks. Continuous data were expressed as mean difference and 95% confidence intervals (CI).

Heterogeneity and sensitivity analysis in the studies

Heterogeneity was evaluated with I2 statistics, in which I2 values of 70% or more represented an indicator of substantial heterogeneity. In the absence of this heterogeneity, we pooled data with a fixed-effect model (I2<50%); otherwise, we used a random-effects model (I2>50%). Results were considered statistically significant at p<0.05.

Data analysis and critical evaluation

Study quality assessment included study design, level of evidence, and the New Castle score (Ottawa Quality Assessment Cohort Studies) (accessed July 2019) for nonrandomized clinical trials (99. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa, ON: Ottawa Hospital Research Institute. 2000. [Accessed May 24th, 2020]. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
http://www.ohri.ca/programs/clinical_epi...
).

RESULTS

Study selection

Using the search strategy mentioned above, we identified 1688 articles, of which 488 articles were from PubMed/MEDLINE, 861 from EMBASE, and 289 from Cochrane Library. After applying the previously defined inclusion and exclusion criteria, 73 articles were selected in the PICO structure, and 27 were eventually included in the meta-analysis, as shown in Figure 1.

Figure 1
Flow chart of eligible studies selection according to the PRISMA statement.

The New Castle-Ottawa Scale (NOS) qualification of the studies for non-tumoral PVT in LT and the overall demographics data of selected studies are depicted in Tables 1 and 2, respectively. Table 2 also shows the extent of thrombosis in the portal system according to the Yerdel classification and the types of surgical techniques employed. Thrombectomy was performed in 932 patients, SMV jump graft in 95, interposition vein graft in 23, collateral anastomosis in 32, renoportal anastomosis in 27, and CPH in 50 (Table 2).

Meta-analysis

For the meta-analysis, 27 articles were selected (55. Yerdel MA, Gunson B, Mirza D, Karayalçin K, Olliff S, Buckels J, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69(9):1873-81. https://doi.org/10.1097/00007890-200005150-00023.
https://doi.org/10.1097/00007890-2000051...
,1010. Bertelli R, Nardo B, Montalti R, Beltempo P, Puviani L, Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center. Transplant Proc. 2005;37(2):1119-21. https://doi.org/10.1016/j.transproceed.2005.01.031.
https://doi.org/10.1016/j.transproceed.2...

11. Tao YF, Teng F, Wang ZX, Guo WY, Shi XM, Wang GH, et al. Liver transplant recipients with portal vein thrombosis: a single center retrospective study. Hepatobiliary Pancreat Dis Int. 2009;8(1):34-9.

12. Suarez Artacho G, Barrera Pulido L, Alamo Martinez JM, Serrano Diez-Canedo J, Bernal Bellido C, Marin Gomez LM, et al. Outcomes of liver transplantation in candidates with portal vein thrombosis. Transplant Proc. 2010;42(8):3156-8. https://doi.org/10.1016/j.transproceed.2010.05.057.
https://doi.org/10.1016/j.transproceed.2...

13. Arcadipane A, Nadalin S, Gruttadauria S, Panarello G, Burgio G, Vizzini G, et al. The recipient with portal thrombosis and/or previous surgery. Transplant Proc. 2008;40(4):1183-6. https://doi.org/10.1016/j.transproceed.2008.03.073.
https://doi.org/10.1016/j.transproceed.2...

14. Wu TH, Lin YS, Lee CF, Wu TJ, Yu MC, Chan KM, et al. Clinical analysis and strategy for liver transplantation in patients with pre-existing portal vein thrombosis. Chang Gung Med J. 2011;34(4):426-34.

15. Englesbe MJ, Schaubel DE, Cai S, Guidinger MK, Merion RM. Portal vein thrombosis and liver transplant survival benefit. Liver Transpl. 2010;16(8):999-1005. https://doi.org/10.1002/lt.22105.
https://doi.org/10.1002/lt.22105...

16. Ravaioli M, Zanello M, Grazi GL, Ercolani G, Cescon M, Del Gaudio M, et al. Portal vein thrombosis and liver transplantation: evolution during 10 years of experience at the University of Bologna. Ann Surg. 2011;253(2):378-84. https://doi.org/10.1097/SLA.0b013e318206818b.
https://doi.org/10.1097/SLA.0b013e318206...

17. Hernández-Conde M, Llop Herrera E, de la Revilla Negro J, Pons Renedo F, Fernández Puga N, Martínez-Porras JL, et al. Prevalence and outcome of portal thrombosis in a cohort of cirrhotic patients undergoing liver transplantation. Rev Esp Enferm Dig. 2016;108(11):716-20.

18. Gimeno FA, Calvo J, Loinaz C, Meneu JC, Pérez B, Gomez R, et al. Comparative analysis of the results of orthotopic liver transplantation in patients with and without portal vein thrombosis. Transplant Proc. 2005;37(9):3899-903. https://doi.org/10.1016/j.transproceed.2005.10.085.
https://doi.org/10.1016/j.transproceed.2...

19. Hibi T, Nishida S, Levi DM, Selvaggi G, Tekin A, Fan J, et al. When and why portal vein thrombosis matters in liver transplantation: a critical audit of 174 cases. Ann Surg. 2014;259(4):760-6. https://doi.org/10.1097/SLA.0000000000000252.
https://doi.org/10.1097/SLA.000000000000...

20. Kim SJ, Kim DG, Park JH, Moon IS, Lee MD, Kim JI, et al. Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2011;25(1):111-8. https://doi.org/10.1111/j.1399-0012.2010.01217.x.
https://doi.org/10.1111/j.1399-0012.2010...

21. Lladó L, Fabregat J, Castellote J, Ramos E, Torras J, Jorba R, et al. Management of portal vein thrombosis in liver transplantation: influence on morbidity and mortality. Clin Transplant. 2007;21(6):716-21. https://doi.org/10.1111/j.1399-0012.2007.00728.x.
https://doi.org/10.1111/j.1399-0012.2007...

22. D’Amico G, Tarantino G, Spaggiari M, Ballarin R, Serra V, Rumpianesi G, et al. Multiple ways to manage portal thrombosis during liver transplantation: surgical techniques and outcomes. Transplant Proc. 2013;45(7):2692-9. https://doi.org/10.1016/j.transproceed.2013.07.046.
https://doi.org/10.1016/j.transproceed.2...

23. Gao PJ, Gao J, Li Z, Hu ZP, Leng XS, Zhu JY. Liver transplantation in adults with portal vein thrombosis: Data from the China Liver Transplant Registry. Clin Res Hepatol Gastroenterol. 2016;40(3):327-32. https://doi.org/10.1016/j.clinre.2015.05.010.
https://doi.org/10.1016/j.clinre.2015.05...

24. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
https://doi.org/10.1111/ctr.12803...

25. Pan C, Shi Y, Zhang JJ, Deng YL, Zheng H, Zhu ZJ, et al. Single-center experience of 253 portal vein thrombosis patients undergoing liver transplantation in China. Transplant Proc. 2009;41(9):3761-5. https://doi.org/10.1016/j.transproceed.2009.06.215.
https://doi.org/10.1016/j.transproceed.2...

26. Cho JY, Suh KS, Shin WY, Lee HW, Yi NJ, Lee KU. Thrombosis confined to the portal vein is not a contraindication for living donor liver transplantation. World J Surg. 2008;32(8):1731-7. https://doi.org/10.1007/s00268-008-9651-4.
https://doi.org/10.1007/s00268-008-9651-...

27. Loinaz C, Gómez R, Jiménez J, González-Pinto I, García I, Gimeno A, et al. Liver transplantation in patients with portal thrombosis: results in 76 patients. Transplant Proc. 2002;34(1):248-9. https://doi.org/10.1016/S0041-1345(01)02746-4.
https://doi.org/10.1016/S0041-1345(01)02...

28. Bhangui P, Lim C, Salloum C, Andreani P, Sebbagh M, Hoti E, et al. Caval inflow to the graft for liver transplantation in patients with diffuse portal vein thrombosis: a 12-year experience. Ann Surg. 2011;254(6):1008-16. https://doi.org/10.1097/SLA.0b013e31822d7894.
https://doi.org/10.1097/SLA.0b013e31822d...

29. Molmenti EP, Roodhouse TW, Molmenti H, Jaiswal K, Jung G, Marubashi S, et al. Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation. Ann Surg. 2002;235(2):292-6. https://doi.org/10.1097/00000658-200202000-00019.
https://doi.org/10.1097/00000658-2002020...

30. Gayowski TJ, Marino IR, Doyle HR, Echeverri L, Mieles L, Todo S, et al. A high incidence of native portal vein thrombosis in veterans undergoing liver transplantation. J Surg Res. 1996;60(2):333-8. https://doi.org/10.1006/jsre.1996.0053.
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31. Seu P, Shackleton CR, Shaked A, Imagawa DK, Olthoff KM, Rudich SR, et al. Improved results of liver transplantation in patients with portal vein thrombosis. Arch Surg. 1996;131(8):840-4; discussion 844-5. https://doi.org/10.1001/archsurg.1996.01430200050009.
https://doi.org/10.1001/archsurg.1996.01...

32. Lerut JP, Mazza D, van Leeuw V, Laterre PF, Donataccio M, de Ville de Goyet J, et al. Adult liver transplantation and abnormalities of splanchnic veins: experience in 53 patients. Transpl Int. 1997;10(2):125-32. https://doi.org/10.1111/j.1432-2277.1997.tb00554.x.
https://doi.org/10.1111/j.1432-2277.1997...

33. Karatzas T, Lykaki-Karatzas E, Demirbas A, Tsaroucha A, Phipps J, Nery J, et al. Management of portal vein thrombosis in liver transplantation. Transplant Proc. 1997;29(7):2866-7. https://doi.org/10.1016/S0041-1345(97)00711-2.
https://doi.org/10.1016/S0041-1345(97)00...

34. Dumortier J, Czyglik O, Poncet G, Blanchet MC, Boucaud C, Henry L, et al. Eversion thrombectomy for portal vein thrombosis during liver transplantation. Am J Transplant. 2002;2(10):934-8. https://doi.org/10.1034/j.1600-6143.2002.21009.x.
https://doi.org/10.1034/j.1600-6143.2002...
-3535. Lendoire J, Raffin G, Cejas N, Duek F, Barros Schelotto P, Trigo P, et al. Liver transplantation in adult patients with portal vein thrombosis: risk factors, management and outcome. HPB (Oxford). 2007;9(5):352-6. https://doi.org/10.1080/13651820701599033.
https://doi.org/10.1080/1365182070159903...
). Different articles were used for specific data analysis, as shown below:

  • Surgery time-7 articles (1010. Bertelli R, Nardo B, Montalti R, Beltempo P, Puviani L, Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center. Transplant Proc. 2005;37(2):1119-21. https://doi.org/10.1016/j.transproceed.2005.01.031.
    https://doi.org/10.1016/j.transproceed.2...
    ,1313. Arcadipane A, Nadalin S, Gruttadauria S, Panarello G, Burgio G, Vizzini G, et al. The recipient with portal thrombosis and/or previous surgery. Transplant Proc. 2008;40(4):1183-6. https://doi.org/10.1016/j.transproceed.2008.03.073.
    https://doi.org/10.1016/j.transproceed.2...
    ,2020. Kim SJ, Kim DG, Park JH, Moon IS, Lee MD, Kim JI, et al. Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2011;25(1):111-8. https://doi.org/10.1111/j.1399-0012.2010.01217.x.
    https://doi.org/10.1111/j.1399-0012.2010...

    21. Lladó L, Fabregat J, Castellote J, Ramos E, Torras J, Jorba R, et al. Management of portal vein thrombosis in liver transplantation: influence on morbidity and mortality. Clin Transplant. 2007;21(6):716-21. https://doi.org/10.1111/j.1399-0012.2007.00728.x.
    https://doi.org/10.1111/j.1399-0012.2007...

    22. D’Amico G, Tarantino G, Spaggiari M, Ballarin R, Serra V, Rumpianesi G, et al. Multiple ways to manage portal thrombosis during liver transplantation: surgical techniques and outcomes. Transplant Proc. 2013;45(7):2692-9. https://doi.org/10.1016/j.transproceed.2013.07.046.
    https://doi.org/10.1016/j.transproceed.2...

    23. Gao PJ, Gao J, Li Z, Hu ZP, Leng XS, Zhu JY. Liver transplantation in adults with portal vein thrombosis: Data from the China Liver Transplant Registry. Clin Res Hepatol Gastroenterol. 2016;40(3):327-32. https://doi.org/10.1016/j.clinre.2015.05.010.
    https://doi.org/10.1016/j.clinre.2015.05...
    -2424. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
    https://doi.org/10.1111/ctr.12803...
    );

  • Intraoperative transfusion of blood-borne products-8 articles (1010. Bertelli R, Nardo B, Montalti R, Beltempo P, Puviani L, Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center. Transplant Proc. 2005;37(2):1119-21. https://doi.org/10.1016/j.transproceed.2005.01.031.
    https://doi.org/10.1016/j.transproceed.2...
    ,1313. Arcadipane A, Nadalin S, Gruttadauria S, Panarello G, Burgio G, Vizzini G, et al. The recipient with portal thrombosis and/or previous surgery. Transplant Proc. 2008;40(4):1183-6. https://doi.org/10.1016/j.transproceed.2008.03.073.
    https://doi.org/10.1016/j.transproceed.2...
    ,2121. Lladó L, Fabregat J, Castellote J, Ramos E, Torras J, Jorba R, et al. Management of portal vein thrombosis in liver transplantation: influence on morbidity and mortality. Clin Transplant. 2007;21(6):716-21. https://doi.org/10.1111/j.1399-0012.2007.00728.x.
    https://doi.org/10.1111/j.1399-0012.2007...
    ,2222. D’Amico G, Tarantino G, Spaggiari M, Ballarin R, Serra V, Rumpianesi G, et al. Multiple ways to manage portal thrombosis during liver transplantation: surgical techniques and outcomes. Transplant Proc. 2013;45(7):2692-9. https://doi.org/10.1016/j.transproceed.2013.07.046.
    https://doi.org/10.1016/j.transproceed.2...
    ,2424. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
    https://doi.org/10.1111/ctr.12803...

    25. Pan C, Shi Y, Zhang JJ, Deng YL, Zheng H, Zhu ZJ, et al. Single-center experience of 253 portal vein thrombosis patients undergoing liver transplantation in China. Transplant Proc. 2009;41(9):3761-5. https://doi.org/10.1016/j.transproceed.2009.06.215.
    https://doi.org/10.1016/j.transproceed.2...

    26. Cho JY, Suh KS, Shin WY, Lee HW, Yi NJ, Lee KU. Thrombosis confined to the portal vein is not a contraindication for living donor liver transplantation. World J Surg. 2008;32(8):1731-7. https://doi.org/10.1007/s00268-008-9651-4.
    https://doi.org/10.1007/s00268-008-9651-...
    -2727. Loinaz C, Gómez R, Jiménez J, González-Pinto I, García I, Gimeno A, et al. Liver transplantation in patients with portal thrombosis: results in 76 patients. Transplant Proc. 2002;34(1):248-9. https://doi.org/10.1016/S0041-1345(01)02746-4.
    https://doi.org/10.1016/S0041-1345(01)02...
    );

  • Intensive care unit (ICU) and hospital length of stay-5 articles (1010. Bertelli R, Nardo B, Montalti R, Beltempo P, Puviani L, Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center. Transplant Proc. 2005;37(2):1119-21. https://doi.org/10.1016/j.transproceed.2005.01.031.
    https://doi.org/10.1016/j.transproceed.2...
    ,1313. Arcadipane A, Nadalin S, Gruttadauria S, Panarello G, Burgio G, Vizzini G, et al. The recipient with portal thrombosis and/or previous surgery. Transplant Proc. 2008;40(4):1183-6. https://doi.org/10.1016/j.transproceed.2008.03.073.
    https://doi.org/10.1016/j.transproceed.2...
    ,2121. Lladó L, Fabregat J, Castellote J, Ramos E, Torras J, Jorba R, et al. Management of portal vein thrombosis in liver transplantation: influence on morbidity and mortality. Clin Transplant. 2007;21(6):716-21. https://doi.org/10.1111/j.1399-0012.2007.00728.x.
    https://doi.org/10.1111/j.1399-0012.2007...
    ,2626. Cho JY, Suh KS, Shin WY, Lee HW, Yi NJ, Lee KU. Thrombosis confined to the portal vein is not a contraindication for living donor liver transplantation. World J Surg. 2008;32(8):1731-7. https://doi.org/10.1007/s00268-008-9651-4.
    https://doi.org/10.1007/s00268-008-9651-...
    ,2929. Molmenti EP, Roodhouse TW, Molmenti H, Jaiswal K, Jung G, Marubashi S, et al. Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation. Ann Surg. 2002;235(2):292-6. https://doi.org/10.1097/00000658-200202000-00019.
    https://doi.org/10.1097/00000658-2002020...
    )

  • Overall survival comparison between PVT and non-PVT patients-19 articles for 1-year survival (55. Yerdel MA, Gunson B, Mirza D, Karayalçin K, Olliff S, Buckels J, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69(9):1873-81. https://doi.org/10.1097/00007890-200005150-00023.
    https://doi.org/10.1097/00007890-2000051...
    ,1010. Bertelli R, Nardo B, Montalti R, Beltempo P, Puviani L, Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center. Transplant Proc. 2005;37(2):1119-21. https://doi.org/10.1016/j.transproceed.2005.01.031.
    https://doi.org/10.1016/j.transproceed.2...

    11. Tao YF, Teng F, Wang ZX, Guo WY, Shi XM, Wang GH, et al. Liver transplant recipients with portal vein thrombosis: a single center retrospective study. Hepatobiliary Pancreat Dis Int. 2009;8(1):34-9.
    -1212. Suarez Artacho G, Barrera Pulido L, Alamo Martinez JM, Serrano Diez-Canedo J, Bernal Bellido C, Marin Gomez LM, et al. Outcomes of liver transplantation in candidates with portal vein thrombosis. Transplant Proc. 2010;42(8):3156-8. https://doi.org/10.1016/j.transproceed.2010.05.057.
    https://doi.org/10.1016/j.transproceed.2...
    ,1414. Wu TH, Lin YS, Lee CF, Wu TJ, Yu MC, Chan KM, et al. Clinical analysis and strategy for liver transplantation in patients with pre-existing portal vein thrombosis. Chang Gung Med J. 2011;34(4):426-34.

    15. Englesbe MJ, Schaubel DE, Cai S, Guidinger MK, Merion RM. Portal vein thrombosis and liver transplant survival benefit. Liver Transpl. 2010;16(8):999-1005. https://doi.org/10.1002/lt.22105.
    https://doi.org/10.1002/lt.22105...

    16. Ravaioli M, Zanello M, Grazi GL, Ercolani G, Cescon M, Del Gaudio M, et al. Portal vein thrombosis and liver transplantation: evolution during 10 years of experience at the University of Bologna. Ann Surg. 2011;253(2):378-84. https://doi.org/10.1097/SLA.0b013e318206818b.
    https://doi.org/10.1097/SLA.0b013e318206...
    -1717. Hernández-Conde M, Llop Herrera E, de la Revilla Negro J, Pons Renedo F, Fernández Puga N, Martínez-Porras JL, et al. Prevalence and outcome of portal thrombosis in a cohort of cirrhotic patients undergoing liver transplantation. Rev Esp Enferm Dig. 2016;108(11):716-20.,2222. D’Amico G, Tarantino G, Spaggiari M, Ballarin R, Serra V, Rumpianesi G, et al. Multiple ways to manage portal thrombosis during liver transplantation: surgical techniques and outcomes. Transplant Proc. 2013;45(7):2692-9. https://doi.org/10.1016/j.transproceed.2013.07.046.
    https://doi.org/10.1016/j.transproceed.2...

    23. Gao PJ, Gao J, Li Z, Hu ZP, Leng XS, Zhu JY. Liver transplantation in adults with portal vein thrombosis: Data from the China Liver Transplant Registry. Clin Res Hepatol Gastroenterol. 2016;40(3):327-32. https://doi.org/10.1016/j.clinre.2015.05.010.
    https://doi.org/10.1016/j.clinre.2015.05...

    24. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
    https://doi.org/10.1111/ctr.12803...
    -2525. Pan C, Shi Y, Zhang JJ, Deng YL, Zheng H, Zhu ZJ, et al. Single-center experience of 253 portal vein thrombosis patients undergoing liver transplantation in China. Transplant Proc. 2009;41(9):3761-5. https://doi.org/10.1016/j.transproceed.2009.06.215.
    https://doi.org/10.1016/j.transproceed.2...
    ,2929. Molmenti EP, Roodhouse TW, Molmenti H, Jaiswal K, Jung G, Marubashi S, et al. Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation. Ann Surg. 2002;235(2):292-6. https://doi.org/10.1097/00000658-200202000-00019.
    https://doi.org/10.1097/00000658-2002020...

    30. Gayowski TJ, Marino IR, Doyle HR, Echeverri L, Mieles L, Todo S, et al. A high incidence of native portal vein thrombosis in veterans undergoing liver transplantation. J Surg Res. 1996;60(2):333-8. https://doi.org/10.1006/jsre.1996.0053.
    https://doi.org/10.1006/jsre.1996.0053...

    31. Seu P, Shackleton CR, Shaked A, Imagawa DK, Olthoff KM, Rudich SR, et al. Improved results of liver transplantation in patients with portal vein thrombosis. Arch Surg. 1996;131(8):840-4; discussion 844-5. https://doi.org/10.1001/archsurg.1996.01430200050009.
    https://doi.org/10.1001/archsurg.1996.01...

    32. Lerut JP, Mazza D, van Leeuw V, Laterre PF, Donataccio M, de Ville de Goyet J, et al. Adult liver transplantation and abnormalities of splanchnic veins: experience in 53 patients. Transpl Int. 1997;10(2):125-32. https://doi.org/10.1111/j.1432-2277.1997.tb00554.x.
    https://doi.org/10.1111/j.1432-2277.1997...

    33. Karatzas T, Lykaki-Karatzas E, Demirbas A, Tsaroucha A, Phipps J, Nery J, et al. Management of portal vein thrombosis in liver transplantation. Transplant Proc. 1997;29(7):2866-7. https://doi.org/10.1016/S0041-1345(97)00711-2.
    https://doi.org/10.1016/S0041-1345(97)00...

    34. Dumortier J, Czyglik O, Poncet G, Blanchet MC, Boucaud C, Henry L, et al. Eversion thrombectomy for portal vein thrombosis during liver transplantation. Am J Transplant. 2002;2(10):934-8. https://doi.org/10.1034/j.1600-6143.2002.21009.x.
    https://doi.org/10.1034/j.1600-6143.2002...
    -3535. Lendoire J, Raffin G, Cejas N, Duek F, Barros Schelotto P, Trigo P, et al. Liver transplantation in adult patients with portal vein thrombosis: risk factors, management and outcome. HPB (Oxford). 2007;9(5):352-6. https://doi.org/10.1080/13651820701599033.
    https://doi.org/10.1080/1365182070159903...
    ) and 11 articles for 5-year survival (55. Yerdel MA, Gunson B, Mirza D, Karayalçin K, Olliff S, Buckels J, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69(9):1873-81. https://doi.org/10.1097/00007890-200005150-00023.
    https://doi.org/10.1097/00007890-2000051...
    ,1414. Wu TH, Lin YS, Lee CF, Wu TJ, Yu MC, Chan KM, et al. Clinical analysis and strategy for liver transplantation in patients with pre-existing portal vein thrombosis. Chang Gung Med J. 2011;34(4):426-34.,1616. Ravaioli M, Zanello M, Grazi GL, Ercolani G, Cescon M, Del Gaudio M, et al. Portal vein thrombosis and liver transplantation: evolution during 10 years of experience at the University of Bologna. Ann Surg. 2011;253(2):378-84. https://doi.org/10.1097/SLA.0b013e318206818b.
    https://doi.org/10.1097/SLA.0b013e318206...
    ,1818. Gimeno FA, Calvo J, Loinaz C, Meneu JC, Pérez B, Gomez R, et al. Comparative analysis of the results of orthotopic liver transplantation in patients with and without portal vein thrombosis. Transplant Proc. 2005;37(9):3899-903. https://doi.org/10.1016/j.transproceed.2005.10.085.
    https://doi.org/10.1016/j.transproceed.2...
    ,1919. Hibi T, Nishida S, Levi DM, Selvaggi G, Tekin A, Fan J, et al. When and why portal vein thrombosis matters in liver transplantation: a critical audit of 174 cases. Ann Surg. 2014;259(4):760-6. https://doi.org/10.1097/SLA.0000000000000252.
    https://doi.org/10.1097/SLA.000000000000...
    ,2222. D’Amico G, Tarantino G, Spaggiari M, Ballarin R, Serra V, Rumpianesi G, et al. Multiple ways to manage portal thrombosis during liver transplantation: surgical techniques and outcomes. Transplant Proc. 2013;45(7):2692-9. https://doi.org/10.1016/j.transproceed.2013.07.046.
    https://doi.org/10.1016/j.transproceed.2...

    23. Gao PJ, Gao J, Li Z, Hu ZP, Leng XS, Zhu JY. Liver transplantation in adults with portal vein thrombosis: Data from the China Liver Transplant Registry. Clin Res Hepatol Gastroenterol. 2016;40(3):327-32. https://doi.org/10.1016/j.clinre.2015.05.010.
    https://doi.org/10.1016/j.clinre.2015.05...
    -2424. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
    https://doi.org/10.1111/ctr.12803...
    ,2929. Molmenti EP, Roodhouse TW, Molmenti H, Jaiswal K, Jung G, Marubashi S, et al. Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation. Ann Surg. 2002;235(2):292-6. https://doi.org/10.1097/00000658-200202000-00019.
    https://doi.org/10.1097/00000658-2002020...
    ,3232. Lerut JP, Mazza D, van Leeuw V, Laterre PF, Donataccio M, de Ville de Goyet J, et al. Adult liver transplantation and abnormalities of splanchnic veins: experience in 53 patients. Transpl Int. 1997;10(2):125-32. https://doi.org/10.1111/j.1432-2277.1997.tb00554.x.
    https://doi.org/10.1111/j.1432-2277.1997...
    ,3535. Lendoire J, Raffin G, Cejas N, Duek F, Barros Schelotto P, Trigo P, et al. Liver transplantation in adult patients with portal vein thrombosis: risk factors, management and outcome. HPB (Oxford). 2007;9(5):352-6. https://doi.org/10.1080/13651820701599033.
    https://doi.org/10.1080/1365182070159903...
    );

  • Survival comparison between partial and complete PVT-4 articles (55. Yerdel MA, Gunson B, Mirza D, Karayalçin K, Olliff S, Buckels J, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69(9):1873-81. https://doi.org/10.1097/00007890-200005150-00023.
    https://doi.org/10.1097/00007890-2000051...
    ,1212. Suarez Artacho G, Barrera Pulido L, Alamo Martinez JM, Serrano Diez-Canedo J, Bernal Bellido C, Marin Gomez LM, et al. Outcomes of liver transplantation in candidates with portal vein thrombosis. Transplant Proc. 2010;42(8):3156-8. https://doi.org/10.1016/j.transproceed.2010.05.057.
    https://doi.org/10.1016/j.transproceed.2...
    ,2020. Kim SJ, Kim DG, Park JH, Moon IS, Lee MD, Kim JI, et al. Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2011;25(1):111-8. https://doi.org/10.1111/j.1399-0012.2010.01217.x.
    https://doi.org/10.1111/j.1399-0012.2010...
    ,2424. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
    https://doi.org/10.1111/ctr.12803...
    )

  • Rethrombosis after LT-6 articles (55. Yerdel MA, Gunson B, Mirza D, Karayalçin K, Olliff S, Buckels J, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69(9):1873-81. https://doi.org/10.1097/00007890-200005150-00023.
    https://doi.org/10.1097/00007890-2000051...
    ,1010. Bertelli R, Nardo B, Montalti R, Beltempo P, Puviani L, Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center. Transplant Proc. 2005;37(2):1119-21. https://doi.org/10.1016/j.transproceed.2005.01.031.
    https://doi.org/10.1016/j.transproceed.2...

    11. Tao YF, Teng F, Wang ZX, Guo WY, Shi XM, Wang GH, et al. Liver transplant recipients with portal vein thrombosis: a single center retrospective study. Hepatobiliary Pancreat Dis Int. 2009;8(1):34-9.
    -1212. Suarez Artacho G, Barrera Pulido L, Alamo Martinez JM, Serrano Diez-Canedo J, Bernal Bellido C, Marin Gomez LM, et al. Outcomes of liver transplantation in candidates with portal vein thrombosis. Transplant Proc. 2010;42(8):3156-8. https://doi.org/10.1016/j.transproceed.2010.05.057.
    https://doi.org/10.1016/j.transproceed.2...
    ,2020. Kim SJ, Kim DG, Park JH, Moon IS, Lee MD, Kim JI, et al. Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2011;25(1):111-8. https://doi.org/10.1111/j.1399-0012.2010.01217.x.
    https://doi.org/10.1111/j.1399-0012.2010...
    ,3434. Dumortier J, Czyglik O, Poncet G, Blanchet MC, Boucaud C, Henry L, et al. Eversion thrombectomy for portal vein thrombosis during liver transplantation. Am J Transplant. 2002;2(10):934-8. https://doi.org/10.1034/j.1600-6143.2002.21009.x.
    https://doi.org/10.1034/j.1600-6143.2002...
    )

  • Survival according to Yerdel classification-3 articles (55. Yerdel MA, Gunson B, Mirza D, Karayalçin K, Olliff S, Buckels J, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69(9):1873-81. https://doi.org/10.1097/00007890-200005150-00023.
    https://doi.org/10.1097/00007890-2000051...
    ,2323. Gao PJ, Gao J, Li Z, Hu ZP, Leng XS, Zhu JY. Liver transplantation in adults with portal vein thrombosis: Data from the China Liver Transplant Registry. Clin Res Hepatol Gastroenterol. 2016;40(3):327-32. https://doi.org/10.1016/j.clinre.2015.05.010.
    https://doi.org/10.1016/j.clinre.2015.05...
    ,2424. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
    https://doi.org/10.1111/ctr.12803...
    ) for 1-year and 5-year survival.

Surgery time of LT

Data from seven studies (1010. Bertelli R, Nardo B, Montalti R, Beltempo P, Puviani L, Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center. Transplant Proc. 2005;37(2):1119-21. https://doi.org/10.1016/j.transproceed.2005.01.031.
https://doi.org/10.1016/j.transproceed.2...
,1313. Arcadipane A, Nadalin S, Gruttadauria S, Panarello G, Burgio G, Vizzini G, et al. The recipient with portal thrombosis and/or previous surgery. Transplant Proc. 2008;40(4):1183-6. https://doi.org/10.1016/j.transproceed.2008.03.073.
https://doi.org/10.1016/j.transproceed.2...
,2020. Kim SJ, Kim DG, Park JH, Moon IS, Lee MD, Kim JI, et al. Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2011;25(1):111-8. https://doi.org/10.1111/j.1399-0012.2010.01217.x.
https://doi.org/10.1111/j.1399-0012.2010...

21. Lladó L, Fabregat J, Castellote J, Ramos E, Torras J, Jorba R, et al. Management of portal vein thrombosis in liver transplantation: influence on morbidity and mortality. Clin Transplant. 2007;21(6):716-21. https://doi.org/10.1111/j.1399-0012.2007.00728.x.
https://doi.org/10.1111/j.1399-0012.2007...

22. D’Amico G, Tarantino G, Spaggiari M, Ballarin R, Serra V, Rumpianesi G, et al. Multiple ways to manage portal thrombosis during liver transplantation: surgical techniques and outcomes. Transplant Proc. 2013;45(7):2692-9. https://doi.org/10.1016/j.transproceed.2013.07.046.
https://doi.org/10.1016/j.transproceed.2...

23. Gao PJ, Gao J, Li Z, Hu ZP, Leng XS, Zhu JY. Liver transplantation in adults with portal vein thrombosis: Data from the China Liver Transplant Registry. Clin Res Hepatol Gastroenterol. 2016;40(3):327-32. https://doi.org/10.1016/j.clinre.2015.05.010.
https://doi.org/10.1016/j.clinre.2015.05...
-2424. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
https://doi.org/10.1111/ctr.12803...
) evaluated a total of 22,700 patients (2078 with PVT and 20,622 without PVT). The weighted mean difference was 0.26 minutes [0.22-0.31], p<0.0001 (Figure 2A).

Figure 2
Forrest plot in liver transplantation with non-tumoral portal vein thrombosis (PVT). A. Surgery time. B. Red blood cells. C. Fresh frozen plasma. D. Platelets.

Intraoperative transfusion of blood-borne products

Red blood cells (RBC)

Data from six studies (1010. Bertelli R, Nardo B, Montalti R, Beltempo P, Puviani L, Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center. Transplant Proc. 2005;37(2):1119-21. https://doi.org/10.1016/j.transproceed.2005.01.031.
https://doi.org/10.1016/j.transproceed.2...
,1313. Arcadipane A, Nadalin S, Gruttadauria S, Panarello G, Burgio G, Vizzini G, et al. The recipient with portal thrombosis and/or previous surgery. Transplant Proc. 2008;40(4):1183-6. https://doi.org/10.1016/j.transproceed.2008.03.073.
https://doi.org/10.1016/j.transproceed.2...
,2222. D’Amico G, Tarantino G, Spaggiari M, Ballarin R, Serra V, Rumpianesi G, et al. Multiple ways to manage portal thrombosis during liver transplantation: surgical techniques and outcomes. Transplant Proc. 2013;45(7):2692-9. https://doi.org/10.1016/j.transproceed.2013.07.046.
https://doi.org/10.1016/j.transproceed.2...
,2424. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
https://doi.org/10.1111/ctr.12803...
,2525. Pan C, Shi Y, Zhang JJ, Deng YL, Zheng H, Zhu ZJ, et al. Single-center experience of 253 portal vein thrombosis patients undergoing liver transplantation in China. Transplant Proc. 2009;41(9):3761-5. https://doi.org/10.1016/j.transproceed.2009.06.215.
https://doi.org/10.1016/j.transproceed.2...
,3636. Figueras J, Llado L, Ramos E, Jaurrieta E, Rafecas A, Fabregat J, et al. Temporary portocaval shunt during liver transplantation with vena cava preservation. Results of a prospective randomized study. Liver Transplant. 2001;7(10):904-11. https://doi.org/10.1053/jlts.2001.27870.
https://doi.org/10.1053/jlts.2001.27870...
) evaluated a total of 4,551 patients (499 with PVT and 4052 without PVT). The mean difference was 0.80 packs [0.61-0.90], p<0.0001 (Figure 2B).

Fresh frozen plasma (FFP)

Data from three studies (1313. Arcadipane A, Nadalin S, Gruttadauria S, Panarello G, Burgio G, Vizzini G, et al. The recipient with portal thrombosis and/or previous surgery. Transplant Proc. 2008;40(4):1183-6. https://doi.org/10.1016/j.transproceed.2008.03.073.
https://doi.org/10.1016/j.transproceed.2...
,2424. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
https://doi.org/10.1111/ctr.12803...
,3131. Seu P, Shackleton CR, Shaked A, Imagawa DK, Olthoff KM, Rudich SR, et al. Improved results of liver transplantation in patients with portal vein thrombosis. Arch Surg. 1996;131(8):840-4; discussion 844-5. https://doi.org/10.1001/archsurg.1996.01430200050009.
https://doi.org/10.1001/archsurg.1996.01...
) evaluated 111 patients with PVT and 559 without PVT. The mean difference was 0.27 packs [0.6-0.48], p=0.01 (Figure 2C).

Platelets

Data from three studies (1313. Arcadipane A, Nadalin S, Gruttadauria S, Panarello G, Burgio G, Vizzini G, et al. The recipient with portal thrombosis and/or previous surgery. Transplant Proc. 2008;40(4):1183-6. https://doi.org/10.1016/j.transproceed.2008.03.073.
https://doi.org/10.1016/j.transproceed.2...
,2424. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
https://doi.org/10.1111/ctr.12803...
,2626. Cho JY, Suh KS, Shin WY, Lee HW, Yi NJ, Lee KU. Thrombosis confined to the portal vein is not a contraindication for living donor liver transplantation. World J Surg. 2008;32(8):1731-7. https://doi.org/10.1007/s00268-008-9651-4.
https://doi.org/10.1007/s00268-008-9651-...
) evaluated 111 patients with PVT and 559 without PVT. The mean difference was 0.24 packs [0.03-0.46], p=0.03 (Figure 2D).

Length of stay

Hospital length of stay

Data from five studies (1010. Bertelli R, Nardo B, Montalti R, Beltempo P, Puviani L, Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center. Transplant Proc. 2005;37(2):1119-21. https://doi.org/10.1016/j.transproceed.2005.01.031.
https://doi.org/10.1016/j.transproceed.2...
,1313. Arcadipane A, Nadalin S, Gruttadauria S, Panarello G, Burgio G, Vizzini G, et al. The recipient with portal thrombosis and/or previous surgery. Transplant Proc. 2008;40(4):1183-6. https://doi.org/10.1016/j.transproceed.2008.03.073.
https://doi.org/10.1016/j.transproceed.2...
,2121. Lladó L, Fabregat J, Castellote J, Ramos E, Torras J, Jorba R, et al. Management of portal vein thrombosis in liver transplantation: influence on morbidity and mortality. Clin Transplant. 2007;21(6):716-21. https://doi.org/10.1111/j.1399-0012.2007.00728.x.
https://doi.org/10.1111/j.1399-0012.2007...
,2626. Cho JY, Suh KS, Shin WY, Lee HW, Yi NJ, Lee KU. Thrombosis confined to the portal vein is not a contraindication for living donor liver transplantation. World J Surg. 2008;32(8):1731-7. https://doi.org/10.1007/s00268-008-9651-4.
https://doi.org/10.1007/s00268-008-9651-...
,2929. Molmenti EP, Roodhouse TW, Molmenti H, Jaiswal K, Jung G, Marubashi S, et al. Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation. Ann Surg. 2002;235(2):292-6. https://doi.org/10.1097/00000658-200202000-00019.
https://doi.org/10.1097/00000658-2002020...
) evaluated 269 patients with PVT and 2937 without PVT. The mean difference was 0.07 days [-0.06-0.19], (p=0.30) (Figure 3A).

Figure 3
Forrest plots in liver transplantation with non-tumoral portal vein thrombosis (PVT). A. Hospital length of stay. B. ICU length of stay.

ICU length of stay

Data from five studies (1010. Bertelli R, Nardo B, Montalti R, Beltempo P, Puviani L, Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center. Transplant Proc. 2005;37(2):1119-21. https://doi.org/10.1016/j.transproceed.2005.01.031.
https://doi.org/10.1016/j.transproceed.2...
,1313. Arcadipane A, Nadalin S, Gruttadauria S, Panarello G, Burgio G, Vizzini G, et al. The recipient with portal thrombosis and/or previous surgery. Transplant Proc. 2008;40(4):1183-6. https://doi.org/10.1016/j.transproceed.2008.03.073.
https://doi.org/10.1016/j.transproceed.2...
,2121. Lladó L, Fabregat J, Castellote J, Ramos E, Torras J, Jorba R, et al. Management of portal vein thrombosis in liver transplantation: influence on morbidity and mortality. Clin Transplant. 2007;21(6):716-21. https://doi.org/10.1111/j.1399-0012.2007.00728.x.
https://doi.org/10.1111/j.1399-0012.2007...
,2626. Cho JY, Suh KS, Shin WY, Lee HW, Yi NJ, Lee KU. Thrombosis confined to the portal vein is not a contraindication for living donor liver transplantation. World J Surg. 2008;32(8):1731-7. https://doi.org/10.1007/s00268-008-9651-4.
https://doi.org/10.1007/s00268-008-9651-...
,2929. Molmenti EP, Roodhouse TW, Molmenti H, Jaiswal K, Jung G, Marubashi S, et al. Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation. Ann Surg. 2002;235(2):292-6. https://doi.org/10.1097/00000658-200202000-00019.
https://doi.org/10.1097/00000658-2002020...
) evaluated 246 patients with PVT and 2,555 without PVT. The mean difference was 0.07 days [-0.06-0.20], (p=0.34) (Figure 3B).

Survival analyses

1-year Patient Survival

Data from 19 studies (55. Yerdel MA, Gunson B, Mirza D, Karayalçin K, Olliff S, Buckels J, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69(9):1873-81. https://doi.org/10.1097/00007890-200005150-00023.
https://doi.org/10.1097/00007890-2000051...
,1010. Bertelli R, Nardo B, Montalti R, Beltempo P, Puviani L, Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center. Transplant Proc. 2005;37(2):1119-21. https://doi.org/10.1016/j.transproceed.2005.01.031.
https://doi.org/10.1016/j.transproceed.2...

11. Tao YF, Teng F, Wang ZX, Guo WY, Shi XM, Wang GH, et al. Liver transplant recipients with portal vein thrombosis: a single center retrospective study. Hepatobiliary Pancreat Dis Int. 2009;8(1):34-9.
-1212. Suarez Artacho G, Barrera Pulido L, Alamo Martinez JM, Serrano Diez-Canedo J, Bernal Bellido C, Marin Gomez LM, et al. Outcomes of liver transplantation in candidates with portal vein thrombosis. Transplant Proc. 2010;42(8):3156-8. https://doi.org/10.1016/j.transproceed.2010.05.057.
https://doi.org/10.1016/j.transproceed.2...
,1414. Wu TH, Lin YS, Lee CF, Wu TJ, Yu MC, Chan KM, et al. Clinical analysis and strategy for liver transplantation in patients with pre-existing portal vein thrombosis. Chang Gung Med J. 2011;34(4):426-34.

15. Englesbe MJ, Schaubel DE, Cai S, Guidinger MK, Merion RM. Portal vein thrombosis and liver transplant survival benefit. Liver Transpl. 2010;16(8):999-1005. https://doi.org/10.1002/lt.22105.
https://doi.org/10.1002/lt.22105...

16. Ravaioli M, Zanello M, Grazi GL, Ercolani G, Cescon M, Del Gaudio M, et al. Portal vein thrombosis and liver transplantation: evolution during 10 years of experience at the University of Bologna. Ann Surg. 2011;253(2):378-84. https://doi.org/10.1097/SLA.0b013e318206818b.
https://doi.org/10.1097/SLA.0b013e318206...
-1717. Hernández-Conde M, Llop Herrera E, de la Revilla Negro J, Pons Renedo F, Fernández Puga N, Martínez-Porras JL, et al. Prevalence and outcome of portal thrombosis in a cohort of cirrhotic patients undergoing liver transplantation. Rev Esp Enferm Dig. 2016;108(11):716-20.,2222. D’Amico G, Tarantino G, Spaggiari M, Ballarin R, Serra V, Rumpianesi G, et al. Multiple ways to manage portal thrombosis during liver transplantation: surgical techniques and outcomes. Transplant Proc. 2013;45(7):2692-9. https://doi.org/10.1016/j.transproceed.2013.07.046.
https://doi.org/10.1016/j.transproceed.2...

23. Gao PJ, Gao J, Li Z, Hu ZP, Leng XS, Zhu JY. Liver transplantation in adults with portal vein thrombosis: Data from the China Liver Transplant Registry. Clin Res Hepatol Gastroenterol. 2016;40(3):327-32. https://doi.org/10.1016/j.clinre.2015.05.010.
https://doi.org/10.1016/j.clinre.2015.05...

24. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
https://doi.org/10.1111/ctr.12803...
-2525. Pan C, Shi Y, Zhang JJ, Deng YL, Zheng H, Zhu ZJ, et al. Single-center experience of 253 portal vein thrombosis patients undergoing liver transplantation in China. Transplant Proc. 2009;41(9):3761-5. https://doi.org/10.1016/j.transproceed.2009.06.215.
https://doi.org/10.1016/j.transproceed.2...
,2929. Molmenti EP, Roodhouse TW, Molmenti H, Jaiswal K, Jung G, Marubashi S, et al. Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation. Ann Surg. 2002;235(2):292-6. https://doi.org/10.1097/00000658-200202000-00019.
https://doi.org/10.1097/00000658-2002020...

30. Gayowski TJ, Marino IR, Doyle HR, Echeverri L, Mieles L, Todo S, et al. A high incidence of native portal vein thrombosis in veterans undergoing liver transplantation. J Surg Res. 1996;60(2):333-8. https://doi.org/10.1006/jsre.1996.0053.
https://doi.org/10.1006/jsre.1996.0053...

31. Seu P, Shackleton CR, Shaked A, Imagawa DK, Olthoff KM, Rudich SR, et al. Improved results of liver transplantation in patients with portal vein thrombosis. Arch Surg. 1996;131(8):840-4; discussion 844-5. https://doi.org/10.1001/archsurg.1996.01430200050009.
https://doi.org/10.1001/archsurg.1996.01...

32. Lerut JP, Mazza D, van Leeuw V, Laterre PF, Donataccio M, de Ville de Goyet J, et al. Adult liver transplantation and abnormalities of splanchnic veins: experience in 53 patients. Transpl Int. 1997;10(2):125-32. https://doi.org/10.1111/j.1432-2277.1997.tb00554.x.
https://doi.org/10.1111/j.1432-2277.1997...

33. Karatzas T, Lykaki-Karatzas E, Demirbas A, Tsaroucha A, Phipps J, Nery J, et al. Management of portal vein thrombosis in liver transplantation. Transplant Proc. 1997;29(7):2866-7. https://doi.org/10.1016/S0041-1345(97)00711-2.
https://doi.org/10.1016/S0041-1345(97)00...

34. Dumortier J, Czyglik O, Poncet G, Blanchet MC, Boucaud C, Henry L, et al. Eversion thrombectomy for portal vein thrombosis during liver transplantation. Am J Transplant. 2002;2(10):934-8. https://doi.org/10.1034/j.1600-6143.2002.21009.x.
https://doi.org/10.1034/j.1600-6143.2002...
-3535. Lendoire J, Raffin G, Cejas N, Duek F, Barros Schelotto P, Trigo P, et al. Liver transplantation in adult patients with portal vein thrombosis: risk factors, management and outcome. HPB (Oxford). 2007;9(5):352-6. https://doi.org/10.1080/13651820701599033.
https://doi.org/10.1080/1365182070159903...
) evaluated 2871 patients with PVT and 30,020 patients without PVT. The odds ratio (OR) was 1.17 [1.06-1.29], p=0.002 (Figure 4A).

Figure 4
Forrest plots in liver transplantation with non-tumoral portal vein thrombosis (PVT). A. 1-year survival. B. 5-year survival.

5-year Patient Survival

Data from 11 studies (55. Yerdel MA, Gunson B, Mirza D, Karayalçin K, Olliff S, Buckels J, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69(9):1873-81. https://doi.org/10.1097/00007890-200005150-00023.
https://doi.org/10.1097/00007890-2000051...
,1414. Wu TH, Lin YS, Lee CF, Wu TJ, Yu MC, Chan KM, et al. Clinical analysis and strategy for liver transplantation in patients with pre-existing portal vein thrombosis. Chang Gung Med J. 2011;34(4):426-34.,1616. Ravaioli M, Zanello M, Grazi GL, Ercolani G, Cescon M, Del Gaudio M, et al. Portal vein thrombosis and liver transplantation: evolution during 10 years of experience at the University of Bologna. Ann Surg. 2011;253(2):378-84. https://doi.org/10.1097/SLA.0b013e318206818b.
https://doi.org/10.1097/SLA.0b013e318206...
,1818. Gimeno FA, Calvo J, Loinaz C, Meneu JC, Pérez B, Gomez R, et al. Comparative analysis of the results of orthotopic liver transplantation in patients with and without portal vein thrombosis. Transplant Proc. 2005;37(9):3899-903. https://doi.org/10.1016/j.transproceed.2005.10.085.
https://doi.org/10.1016/j.transproceed.2...
,1919. Hibi T, Nishida S, Levi DM, Selvaggi G, Tekin A, Fan J, et al. When and why portal vein thrombosis matters in liver transplantation: a critical audit of 174 cases. Ann Surg. 2014;259(4):760-6. https://doi.org/10.1097/SLA.0000000000000252.
https://doi.org/10.1097/SLA.000000000000...
,2222. D’Amico G, Tarantino G, Spaggiari M, Ballarin R, Serra V, Rumpianesi G, et al. Multiple ways to manage portal thrombosis during liver transplantation: surgical techniques and outcomes. Transplant Proc. 2013;45(7):2692-9. https://doi.org/10.1016/j.transproceed.2013.07.046.
https://doi.org/10.1016/j.transproceed.2...

23. Gao PJ, Gao J, Li Z, Hu ZP, Leng XS, Zhu JY. Liver transplantation in adults with portal vein thrombosis: Data from the China Liver Transplant Registry. Clin Res Hepatol Gastroenterol. 2016;40(3):327-32. https://doi.org/10.1016/j.clinre.2015.05.010.
https://doi.org/10.1016/j.clinre.2015.05...
-2424. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
https://doi.org/10.1111/ctr.12803...
,2929. Molmenti EP, Roodhouse TW, Molmenti H, Jaiswal K, Jung G, Marubashi S, et al. Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation. Ann Surg. 2002;235(2):292-6. https://doi.org/10.1097/00000658-200202000-00019.
https://doi.org/10.1097/00000658-2002020...
,3232. Lerut JP, Mazza D, van Leeuw V, Laterre PF, Donataccio M, de Ville de Goyet J, et al. Adult liver transplantation and abnormalities of splanchnic veins: experience in 53 patients. Transpl Int. 1997;10(2):125-32. https://doi.org/10.1111/j.1432-2277.1997.tb00554.x.
https://doi.org/10.1111/j.1432-2277.1997...
,3535. Lendoire J, Raffin G, Cejas N, Duek F, Barros Schelotto P, Trigo P, et al. Liver transplantation in adult patients with portal vein thrombosis: risk factors, management and outcome. HPB (Oxford). 2007;9(5):352-6. https://doi.org/10.1080/13651820701599033.
https://doi.org/10.1080/1365182070159903...
) evaluated 2516 patients with PVT and 24,599 patients without PVT. The OR was 1.12 [1.03-1.22], p=0.01 (Figure 4B).

Partial vs. total PVT 1-year Patient Survival

Data from four studies (55. Yerdel MA, Gunson B, Mirza D, Karayalçin K, Olliff S, Buckels J, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69(9):1873-81. https://doi.org/10.1097/00007890-200005150-00023.
https://doi.org/10.1097/00007890-2000051...
,1212. Suarez Artacho G, Barrera Pulido L, Alamo Martinez JM, Serrano Diez-Canedo J, Bernal Bellido C, Marin Gomez LM, et al. Outcomes of liver transplantation in candidates with portal vein thrombosis. Transplant Proc. 2010;42(8):3156-8. https://doi.org/10.1016/j.transproceed.2010.05.057.
https://doi.org/10.1016/j.transproceed.2...
,2020. Kim SJ, Kim DG, Park JH, Moon IS, Lee MD, Kim JI, et al. Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2011;25(1):111-8. https://doi.org/10.1111/j.1399-0012.2010.01217.x.
https://doi.org/10.1111/j.1399-0012.2010...
,2424. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
https://doi.org/10.1111/ctr.12803...
) evaluated 109 patients with total PVT and 108 patients with partial PVT. The OR was 3.70 [1.70-8.03], p=0.0009 (Figure 5A).

Figure 5
Forrest plots. A. Partial vs Total PVT (1-year survival). B. Rethrombosis C. Yerdel classification-1-year Patients Survival. D. Yerdel classification-5-year Patient Survival.

Rethrombosis after LT

Data from six studies (55. Yerdel MA, Gunson B, Mirza D, Karayalçin K, Olliff S, Buckels J, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69(9):1873-81. https://doi.org/10.1097/00007890-200005150-00023.
https://doi.org/10.1097/00007890-2000051...
,1010. Bertelli R, Nardo B, Montalti R, Beltempo P, Puviani L, Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center. Transplant Proc. 2005;37(2):1119-21. https://doi.org/10.1016/j.transproceed.2005.01.031.
https://doi.org/10.1016/j.transproceed.2...

11. Tao YF, Teng F, Wang ZX, Guo WY, Shi XM, Wang GH, et al. Liver transplant recipients with portal vein thrombosis: a single center retrospective study. Hepatobiliary Pancreat Dis Int. 2009;8(1):34-9.
-1212. Suarez Artacho G, Barrera Pulido L, Alamo Martinez JM, Serrano Diez-Canedo J, Bernal Bellido C, Marin Gomez LM, et al. Outcomes of liver transplantation in candidates with portal vein thrombosis. Transplant Proc. 2010;42(8):3156-8. https://doi.org/10.1016/j.transproceed.2010.05.057.
https://doi.org/10.1016/j.transproceed.2...
,2020. Kim SJ, Kim DG, Park JH, Moon IS, Lee MD, Kim JI, et al. Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2011;25(1):111-8. https://doi.org/10.1111/j.1399-0012.2010.01217.x.
https://doi.org/10.1111/j.1399-0012.2010...
,3434. Dumortier J, Czyglik O, Poncet G, Blanchet MC, Boucaud C, Henry L, et al. Eversion thrombectomy for portal vein thrombosis during liver transplantation. Am J Transplant. 2002;2(10):934-8. https://doi.org/10.1034/j.1600-6143.2002.21009.x.
https://doi.org/10.1034/j.1600-6143.2002...
) evaluated 122 patients with total PVT and 183 patients with partial PVT. The OR for was 3.47 [1.18-10.21], p=0.02 (Figure 5B).

Patient Survival according to Yerdel classification

Data from three studies (55. Yerdel MA, Gunson B, Mirza D, Karayalçin K, Olliff S, Buckels J, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69(9):1873-81. https://doi.org/10.1097/00007890-200005150-00023.
https://doi.org/10.1097/00007890-2000051...
,2323. Gao PJ, Gao J, Li Z, Hu ZP, Leng XS, Zhu JY. Liver transplantation in adults with portal vein thrombosis: Data from the China Liver Transplant Registry. Clin Res Hepatol Gastroenterol. 2016;40(3):327-32. https://doi.org/10.1016/j.clinre.2015.05.010.
https://doi.org/10.1016/j.clinre.2015.05...
,2424. Song S, Kwon CH, Kim JM, Joh JW, Lee SK. Single-center experience of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant. 2016;30(9):1146-51. https://doi.org/10.1111/ctr.12803.
https://doi.org/10.1111/ctr.12803...
) evaluated 77 patients with PVT Yerdel III/IV and 1739 patients with PVT Yerdel I/II. The OR for 1-year and 5-year survival was 2.04 [1.21-3.42], p=0.007, and 0.98 [0.59-1.62], p=0.93, respectively (Figures 5C and 5D).

DISCUSSION

PVT may either be a cause or consequence of cirrhosis decompensation. It is asymptomatic in 50% of cirrhotic patients; however, it may lead to severe complications if symptomatic. Early identification and treatment may lead to a better prognosis of these complex patients. The present systematic review and meta-analysis demonstrated that LT in patients with non-tumoral PVT is associated with higher surgery time, higher intraoperative transfusions, and worse 1- and 5-year patient survival. Occlusive PVT, rethrombosis, and Yerdel III/IV also present worse prognosis.

Gao et al. (2323. Gao PJ, Gao J, Li Z, Hu ZP, Leng XS, Zhu JY. Liver transplantation in adults with portal vein thrombosis: Data from the China Liver Transplant Registry. Clin Res Hepatol Gastroenterol. 2016;40(3):327-32. https://doi.org/10.1016/j.clinre.2015.05.010.
https://doi.org/10.1016/j.clinre.2015.05...
), retrospectively analyzing a large casuistic of more than 1800 PVT patients, showed that the overall surgery time of LT was longer in cases with PVT compared to those without it (2323. Gao PJ, Gao J, Li Z, Hu ZP, Leng XS, Zhu JY. Liver transplantation in adults with portal vein thrombosis: Data from the China Liver Transplant Registry. Clin Res Hepatol Gastroenterol. 2016;40(3):327-32. https://doi.org/10.1016/j.clinre.2015.05.010.
https://doi.org/10.1016/j.clinre.2015.05...
). Our meta-analysis, with more than 2,126 PVT patients, confirmed these results.

PVT is considered a very unfavorable prognostic marker in advanced liver disease. Extensive PVT is positively associated with higher mortality during LT (3030. Gayowski TJ, Marino IR, Doyle HR, Echeverri L, Mieles L, Todo S, et al. A high incidence of native portal vein thrombosis in veterans undergoing liver transplantation. J Surg Res. 1996;60(2):333-8. https://doi.org/10.1006/jsre.1996.0053.
https://doi.org/10.1006/jsre.1996.0053...
). One study particularly found that patients with PVT undergoing LT had longer operation time, increased need for transfusions, and lower survival rate than those without PVT (3535. Lendoire J, Raffin G, Cejas N, Duek F, Barros Schelotto P, Trigo P, et al. Liver transplantation in adult patients with portal vein thrombosis: risk factors, management and outcome. HPB (Oxford). 2007;9(5):352-6. https://doi.org/10.1080/13651820701599033.
https://doi.org/10.1080/1365182070159903...
). Another study revealed similar results, showing that patients with PVT had higher post-transplant mortality than those without PVT. Interestingly, PVT was not associated with increased mortality among patients on the transplant waiting list (1515. Englesbe MJ, Schaubel DE, Cai S, Guidinger MK, Merion RM. Portal vein thrombosis and liver transplant survival benefit. Liver Transpl. 2010;16(8):999-1005. https://doi.org/10.1002/lt.22105.
https://doi.org/10.1002/lt.22105...
).

Other retrospective studies demonstrated higher intraoperative use of FFP and RBC in PVT cases (1010. Bertelli R, Nardo B, Montalti R, Beltempo P, Puviani L, Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center. Transplant Proc. 2005;37(2):1119-21. https://doi.org/10.1016/j.transproceed.2005.01.031.
https://doi.org/10.1016/j.transproceed.2...
,1212. Suarez Artacho G, Barrera Pulido L, Alamo Martinez JM, Serrano Diez-Canedo J, Bernal Bellido C, Marin Gomez LM, et al. Outcomes of liver transplantation in candidates with portal vein thrombosis. Transplant Proc. 2010;42(8):3156-8. https://doi.org/10.1016/j.transproceed.2010.05.057.
https://doi.org/10.1016/j.transproceed.2...
,2222. D’Amico G, Tarantino G, Spaggiari M, Ballarin R, Serra V, Rumpianesi G, et al. Multiple ways to manage portal thrombosis during liver transplantation: surgical techniques and outcomes. Transplant Proc. 2013;45(7):2692-9. https://doi.org/10.1016/j.transproceed.2013.07.046.
https://doi.org/10.1016/j.transproceed.2...
,2929. Molmenti EP, Roodhouse TW, Molmenti H, Jaiswal K, Jung G, Marubashi S, et al. Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation. Ann Surg. 2002;235(2):292-6. https://doi.org/10.1097/00000658-200202000-00019.
https://doi.org/10.1097/00000658-2002020...
,3131. Seu P, Shackleton CR, Shaked A, Imagawa DK, Olthoff KM, Rudich SR, et al. Improved results of liver transplantation in patients with portal vein thrombosis. Arch Surg. 1996;131(8):840-4; discussion 844-5. https://doi.org/10.1001/archsurg.1996.01430200050009.
https://doi.org/10.1001/archsurg.1996.01...
). Similar results were found in this meta-analysis. Intraoperative RBC transfusion was evaluated in a total of 4,551 patients (499 with PVT and 4,052 patients without PVT), and a mean difference was 0.80 packs [0.61-0.90] (p<0.0001) was found. Furthermore, intraoperative transfusion of FFP (p=0.01) and platelets (p=0.03) were also higher, comparing 111 patients with PVT to 559 without PVT.

Another meta-analysis by Zanetto et al. (3737. Zanetto A, Rodriguez-Kastro KI, Germani G, Ferrarese A, Cillo U, Burra P, et al. Mortality in liver transplant recipients with portal vein thrombosis - an updated meta-analysis. Transpl Int. 2018;31(12):1318-29. https://doi.org/10.1111/tri.13353.
https://doi.org/10.1111/tri.13353...
) identified lower 1-year survival and higher 30 days postoperative mortality in patients with PVT undergoing LT. The survival in partial PVT was better than in the total PVT group (3737. Zanetto A, Rodriguez-Kastro KI, Germani G, Ferrarese A, Cillo U, Burra P, et al. Mortality in liver transplant recipients with portal vein thrombosis - an updated meta-analysis. Transpl Int. 2018;31(12):1318-29. https://doi.org/10.1111/tri.13353.
https://doi.org/10.1111/tri.13353...
). We also found lower 1- and 5-year patient survival in the PVT group and lower survival for patients with total occlusive PVT.

Different preoperative strategies have been reported to treat PVT, including anticoagulants and interventional radiology techniques, which may reduce intraoperative technical difficulties and improve outcomes (3838. Hanafy AS, Abd-Elsalam S, Dawoud MM. Randomized controlled trial of rivaroxaban versus warfarin in the management of acute non-neoplastic portal vein thrombosis. Vascul Pharmacol. 2019;113:86-91. https://doi.org/10.1016/j.vph.2018.05.002.
https://doi.org/10.1016/j.vph.2018.05.00...

39. Merola J, Fortune BE, Deng Y, Ciarleglio M, Amirbekian S, Chaudhary N, et al. Transjugular intrahepatic portosystemic shunt creation for cirrhotic portal hypertension is well tolerated among patients with portal vein thrombosis. Eur J Gastroenterol Hepatol. 2018;30(6):668-75. https://doi.org/10.1097/MEG.0000000000001097.
https://doi.org/10.1097/MEG.000000000000...
-4040. Nacif LS, Zanini LY, Waisberg DR, Costa Dos Santos JP, Pereira JM, Pinheiro RS, et al. Adult-to-Adult Living Donor Liver Transplant: Hemodynamic Evaluation, Prognosis, and Recipient Selection. Transplant Proc. 2020;52(5):1299-302. https://doi.org/10.1016/j.transproceed.2020.02.073.
https://doi.org/10.1016/j.transproceed.2...
) and portal vein thrombosis in the living donor (41). In our meta-analysis, thrombectomy with primary anastomosis was associated with better outcomes. Total occlusive PVT presented higher mortality and rethrombosis rates. Accordingly, PVT Yerdel III/IV classification demonstrated worse 1-year and 5-year patient survival.

One limitation of this study is that we found only nonrandomized clinical trials and comparative studies, both prospective and retrospective (Table 1). Therefore, more randomized controlled trials are needed to define more accurate results and improve treatments. Our study shows that proper management of PVT in patients undergoing LT may have real benefit to the clinical practice. Fortunately, some clinical trials are registered in the US National Library of Medicine (https://clinicaltrials.gov). Moreover, we also found in the PROSPERO platform search one ongoing review registered in September 2019 - “Systematic review of surgical techniques for managing porto-mesenteric vein thrombosis in liver transplantation” (PROSPERO Number: CDR42019129755).

Table 1
New Castle-Ottawa Scale (NOS) qualification the studies for non-tumoral portal vein thrombosis (PVT) in liver transplantation.
Table 2
Overall demographics data of the study population of each selected study for non-tumoral portal vein thrombosis (PVT) in liver transplantation.

CONCLUSION

In conclusion, LT in patients with non-tumoral PVT demands more surgical time, needs more intraoperative transfusion, and presents worse 1- and 5-year patient survival. In addition to this, total occlusive PVT presents higher mortality and rethrombosis rates, and PVT Yerdel III/IV classification is associated with worse survival. When feasible, thrombectomy with primary anastomosis is associated with better outcomes.

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Publication Dates

  • Publication in this collection
    20 Jan 2021
  • Date of issue
    2021

History

  • Received
    1 July 2020
  • Accepted
    13 Nov 2020
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