Portal vein recanalisation alone to treat severe portal hypertension in non-cirrhotic patients with chronic extrahepatic portal vein obstruction

Florent Artru; Naik Vietti-Violi; Christine Sempoux; Joana Vieira Barbosa; Fabio Becce; Nelly Sah; Astrid Marot; Pierre Deltenre; Eleni Moschouri; Montserrat Fraga; Arnaud Hocquelet; Rafael Duran; Darius Moradpour; Pierre-Emmanuel Rautou; Alban Denys

doi:10.1016/j.jhepr.2022.100511

Portal vein recanalisation alone to treat severe portal hypertension in non-cirrhotic patients with chronic extrahepatic portal vein obstruction

JHEP Rep. 2022 May 25;4(8):100511. doi: 10.1016/j.jhepr.2022.100511. eCollection 2022 Aug.

Authors

Florent Artru^{1

2}, Naik Vietti-Violi³, Christine Sempoux⁴, Joana Vieira Barbosa¹, Fabio Becce³, Nelly Sah³, Astrid Marot⁵, Pierre Deltenre^{6

7}, Eleni Moschouri¹, Montserrat Fraga¹, Arnaud Hocquelet³, Rafael Duran³, Darius Moradpour¹, Pierre-Emmanuel Rautou⁸, Alban Denys³

Affiliations

¹ Service of Gastroenterology and Hepatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
² Institute of Liver Studies, King's College Hospital, London, UK.
³ Service of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
⁴ Service of Clinical Pathology, Institute of Pathology Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
⁵ Department of Gastroenterology and Hepatology, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium.
⁶ Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.
⁷ Department of Gastroenterology and Hepatology, Clinique St Luc, Bouge, Belgium.
⁸ Université de Paris, AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Paris, France.

Abstract

Background & aims: We aimed to evaluate long-term outcome of patients with chronic non-cirrhotic extrahepatic portal vein obstruction (CNC-EHPVO) who underwent portal vein recanalisation (PVR) without transjugular intrahepatic portosystemic shunt (TIPS) insertion and to determine factors predicting PVR failure and stent occlusion.

Methods: This retrospective monocentric study included all patients who underwent PVR without TIPS insertion in the context of CNC-EHPVO between the years 2000 and 2019. Primary patency was defined by the absence of a complete stent occlusion on follow-up imaging.

Results: A total of 31 patients underwent PVR with a median follow-up of 52 months (24-82 months). Indications were gastrointestinal bleeding (n = 13), abdominal pain attributed to CNC-EHPVO (n = 7), prior to abdominal surgery (n = 4), and others (n = 7). Technical success was obtained in 27 patients. PVR failure was associated with extension within the intrahepatic portal veins (p = 0.005) and recanalisation for abdominal pain (p = 0.02). Adverse events occurred in 6 patients with no mortality. Anticoagulation was administered in 21 patients after technical success of PVR. In patients with technical success, 5-year primary patency was 73% and was associated with improved muscle mass (p = 0.007) and decreased spleen volume (p = 0.01) at 1 year. Furthermore, 21 (78%) patients with PVR technical success were free of portal hypertension complication at 5 years.

Conclusions: PVR without TIPS insertion was feasible and safe in selected patients with CNC-EHPVO and portal hypertension with past or expected complications. Primary patency at 5 years was obtained in 3 of 4 patients with technical success of PVR and was associated with a control of complications of CNC-EHPVO. PVR was associated with improvement of sarcopenia and decreased spleen volume at 1 year.

Lay summary: Patients with chronic obstruction of the portal vein and without cirrhosis or malignancy can develop complications related to the high pressure in the venous system. The present study reports long-term favourable outcome of patients in whom the obstruction was treated with stents.

Keywords: CNC-EHPVO, chronic noncirrhotic extrahepatic portal vein obstruction; Chronic non-cirrhotic extrahepatic portal vein obstruction (CNC-EHPVO); DICOM, digital imaging and communications in medicine; EHPVO, extrahepatic portal vein obstruction; Gastrointestinal bleeding; HE, hepatic encephalopathy; L3, lumbar 3; L3SMI, skeletal muscle index at L3; L4, lumbar 4; NFH, non-fractioned heparin; PVR, portal vein recanalisation; Portal cholangiopathy; Portal hypertension; Portal vein recanalisation; SMI, skeletal muscle index; SMV, superior mesenteric vein; SV, splenic vein; Sarcopenia; TIPS, transjugular intrahepatic portosystemic shunt; TPMA, total psoas muscle area; US, ultrasound.