Management of portal vein thrombosis in candidates for liver transplant

Portal vein thrombosis (PVT) is a frequent event among patients with advanced liver disease, with a prevalence reaching up to 26% in those awaiting liver transplantation (LT). Extensive thrombosis affecting the mesenteric vein confluence correlates with increased morbidity and mortality post-LT, particularly when it impedes physiological anastomosis or contraindicates the LT. Current guidelines advocate for routine PVT screening in all potential liver transplant candidates and prompt treatment upon detection. The main objective of candidates for LT is to facilitate physiological portal-to-portal anastomosis. Anticoagulation serves as the first-line therapy, achieving recanalization rates between 33% and 75%. Discontinuation of anticoagulation significantly heightens the risk of rethrombosis in a substantial proportion of patients; therefore, it is recommended to continue anticoagulation until LT for those awaiting LT or potential candidates for LT. Nevertheless, 30%-60% of patients fail to respond to anticoagulation, with PVT progression occurring in up to 14% despite anticoagulation. In such cases, TIPS placement emerges as a viable alternative to maintain portal vein patency. While the feasibility of TIPS placement diminished with the presence of portal cavernoma or chronic PVT, the introduction of novel interventional radiological techniques to recanalize the portal venous axis through transplenic, transmesenteric, and/or transhepatic routes is revolutionizing this landscape. These advancements achieve TIPS placement and recanalization in 90%-100% of patients, warranting consideration in patients with cirrhosis with chronic PVT for whom LT would otherwise be contraindicated or when physiological anastomosis is not feasible.