Management of Thrombosis in the Liver Transplant Candidate

Liver cirrhosis is associated with thrombotic complications. Both local and systemic factors can result in the development of this site-specific thrombosis. The portal vein is the most common site for thrombus formation, with 1-year incidence ranging from 7.4 to 11%. The association between liver cirrhosis and peripheral venous thromboembolism has been described in 0.8–7% of hospitalized cirrhotic patients. Another thrombotic complication that can lead to liver failure and the need for a liver transplantation is a thrombotic obstruction of hepatic venous outflow defined as Budd-Chiari syndrome (BCS). BCS occurs in 0.2 per million per year with a prevalence ranging from 1/1.000.000 of the general population in the East up to 1/100.000 in Nepal. Treatment of thrombotic complications in cirrhotic patients is based on anticoagulation, which has been demonstrated to be both safe and effective. The early initiation of anticoagulant therapy after the development of portal thrombosis is the most important factor for predicting a response to therapy, with a recanalization rate of up to 75% for PVT in cirrhosis and 30% in patients with BCS. For patients who do not respond adequately to medical therapy, TIPS can be attempted. In BCS angioplasty/stenting/thrombolysis can be considered as the second-line treatment, and TIPS is the treatment of choice when thrombosis affects multiple hepatic veins or in cases of severe ascites. Finally, liver transplantation remains the treatment of choice in cirrhotics who have PVT, in cases of hyperacute presentation of BCS, and in cases in which TIPS has failed.