Specialty (if any): Radiology/Hepatology

Keywords: TIPS, CT scan, Portal Vein Thrombosis

Background:
Portal vein thrombosis (PVT) is the formation of a clot within the main portal vein, potentially extending into its smaller branches. It is reported to occur in 1% to 25% of cases. Factors that may contribute to PVT include reduced portal vein flow velocity and concurrent thrombophilic disorders. In patients with cirrhosis and portal hypertension, transjugular intrahepatic portosystemic shunt (TIPS) is a well-established treatment for managing variceal bleeding or ascites that does not respond to other therapies.

Patients with thrombosis affecting less than 50% of the lumen of the main portal vein or intrahepatic branches can be monitored every three months for thrombosis progression, unless they are on the liver transplant waiting list or the superior mesenteric vein is involved, which warrants anticoagulation. Those who are potential liver transplant candidates or have progressive or occlusive portal vein thrombosis (PVT) with more than 50% occlusion of the main portal vein or both intrahepatic branches should undergo treatment. Anticoagulation is the preferred initial treatment if the main portal vein is identifiable and there is no cavernoma. Transjugular intrahepatic portosystemic shunt (TIPS) is typically reserved for patients who do not respond to six months of anticoagulation. However, it may be considered as first-line therapy in certain situations, such as significant complications of portal hypertension (e.g., variceal hemorrhage, refractory ascites) requiring TIPS, identification of an old thrombus (>6 months) unlikely to respond to anticoagulation in a transplant candidate, or contraindications to anticoagulation.

Previous studies have highlighted disparities in healthcare, particularly regarding access to liver transplantation, management of hepatocellular carcinoma, and gastrointestinal hemorrhage. One study found ongoing challenges in liver transplant and organ donation processes. The aim of this study was to focus on factors affecting the likelihood of cirrhotic patients with portal vein thrombosis receiving TIPS treatment and timely follow-up with CT scans after anticoagulant therapy

Objective: The transjugular intrahepatic portosystemic shunt (TIPS), thrombectomy, and follow up CT scan at 3-6 months are important steps in management patients with portal vein thrombosis with >50% occlusion/progressive PVT of the trunk or both main branches in a potential transplant candidate. The objective of this study was to identify factors that might negatively affect the likelihood patients might receive TIPS on time or loss in follow up with CT scan at 3-6 months.

Methods:
The study identified cirrhotic patients with portal vein thrombosis between 2017 and 2022. The primary outcomes of interest were whether patients underwent TIPS treatment and whether they received a follow-up CT scan 3-6 months after six months of anticoagulation therapy. The independent variables included patient primary language, race, and insurance type. Odds ratios were calculated, and a χ2 test were conducted.

Results:

383 patients were included in the study. Approximately, 5.2% were classified as black, 8.3% as Hispanic, 40% as Caucasian, and 45.4% as belonging to other racial or ethnic groups. Regarding primary language, 78.3% spoke English, 16.4% spoke Spanish, and 5.22% spoke other languages. Among these patients, 51.1% were covered by public insurance (either Medi-Cal or Medicare), while 48.5% had private insurance. The preliminary data indicated that patients not classified as Caucasian, Black, or Hispanic had an increased likelihood of not receiving a repeat CT scan after anticoagulation treatment (OR 2.34, 95% CI 1.43-2.65) and an increased likelihood of delayed TIPS treatment (OR 3.56, 95% CI 2.5-4.56).

Conclusions:

This cohort study highlights issues in the care of patients with portal vein thrombosis, showing that certain subgroups experienced more suboptimal follow-up and delays in receiving TIPS treatment compared to other cohorts. Further research is necessary to explore ways to improve the care of these patients with portal vein thrombosis.