Clinical and Molecular Hepatology

"Portal vein thrombosis"

Review

Update in the treatment of cirrhotic patients with portal vein thrombosis: Jialin Wu, Xinyi Deng, Junyang Luo, Zaibo Jiang, Fuda Xie, Bonan Chen, Hoi Wing Leung, Ge Zhang, Ka Fai To, Wei Kang; Clin Mol Hepatol 2025;31(4):1139-1166.
Published online June 24, 2025; DOI: https://doi.org/10.3350/cmh.2025.0411

Abstract
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Portal vein thrombosis (PVT) is characterized by the formation of a thrombus (blood clot) within the portal vein system, including main portal vein and its intrahepatic portal vein branches, and may extend to the superior mesenteric vein or splenic vein. The emergence of PVT is linked to diverse risk factors, encompassing liver conditions with cirrhosis, abdominal infections, previous abdominal surgeries, malignancies, inherited or acquired thrombophilias, and systemic hypercoagulable conditions. Recent studies revealed a possible connection between the occurrence of PVT and either contracting corona virus disease 2019 (COVID-19) or receiving a COVID-19 vaccination. Current treatment strategies were primarily based on symptom management, extent, and progression of thrombosis, but their efficacy was inconsistent and suboptimal. Untimely or inadequate treatment can lead to the progression of the thrombus and increase the risk of complications, such as portal hypertension, variceal bleeding, and hepatic decompensation, posing a significant risk to the patient’s life. Thus, early and appropriate initiation of pharmacologic and interventional treatments, as well as more aggressive strategies, is crucial for the management and prevention of PVT progression and recurrence. This review focuses on the literature on the recent advancements in the treatment of PVT using various therapeutic modalities, including anticoagulant therapy, thrombolysis, thrombectomy, interventional therapy and liver transplant in cirrhotic patients. In addition, we discuss pearls and pitfalls of these strategies for PVT, highlighting recent progress, identifying knowledge gaps, and proposing avenues towards precision management.

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Gastrointestinal bleeding risk in cirrhotic portal vein thrombosis: focus on thrombus extension to superior mesenteric vein
Sa Lv, Hui Feng, Tianjiao Xu, Hua Tian, Haibo Wang, Dongze Li, Shaoli You, Bing Zhu
BMC Gastroenterology.2026;[Epub] CrossRef
Acute portal vein thrombosis in an elderly man with homozygous mutations of plasminogen activator inhibitor-1 and methylenetetrahydrofolate reductase genes
Junxiu Chen, Haonan Zhao, Shengye Yang, Huiyuan Lu, Xingshun Qi
Archives of Medical Science.2025;[Epub] CrossRef
Prediction of bowel resection due to bowel necrosis in recent portal vein thrombosis based on CT presentations and clinical data
Junyang Luo, Junwei Chen, Hua Tang, Jialin Wu, Xiaohong Wang, Zaibo Jiang, Jie Qin
BMC Gastroenterology.2025;[Epub] CrossRef
Long-term patency of the transjugular intrahepatic portosystemic shunt for portal and superior mesenteric vein thrombosis
Junyang Luo, Churen Zhou, Yanyang Zhang, Haofan Wang, Caiyun Lu, Jialin Wu, Jie Qin, Zaibo Jiang, Junwei Chen
Thrombosis Journal.2025;[Epub] CrossRef

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Case Reports

Hepatic neoplasm

Complete cure of advanced hepatocellular carcinoma with right adrenal gland metastasis and portal vein thrombosis by multiple applications of an interdisciplinary therapy: case report with 8-year follow up: Hojung Jung, Byung Ik Kim, Yong Kyun Cho, Woo Kyu Jeon, Hong Joo Kim, Hyun Pyo Hong; Clin Mol Hepatol 2018;24(4):424-429.
Published online November 14, 2017; DOI: https://doi.org/10.3350/cmh.2017.0032

Abstract
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Hepatocellular carcinoma (HCC) is the sixth most common cause of death worldwide and the main cause of primary liver cancer. The principle problem of HCC is the poor prognosis, since advanced HCC reportedly has a median survival of only 9 months. The standard therapies are sorafenib and regorafenib, but the outcomes remain unclear. We report a 60-year-old man with advanced HCC with right adrenal gland metastasis and portal vein tumor thrombosis, who showed a complete response to multiple applications of an interdisciplinary therapy.

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Long-term sustained complete response with off-therapy to sorafenib in advanced hepatocellular carcinoma: a case report
Takeshi Koujima, Yoshikatsu Endo, Takeharu Yamamoto, Toshifumi Tada, Kazuhiko Morii, Shinichiro Nakamura, Kyohei Kai
Kanzo.2020; 61(5): 255. CrossRef

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Liver fibrosis, cirrhosis, and portal hypertension

Recurrent acute portal vein thrombosis in liver cirrhosis treated by rivaroxaban: Hyeyoung Yang, Seo Ree Kim, Myeong Jun Song; Clin Mol Hepatol 2016;22(4):499-502.
Published online November 25, 2016; DOI: https://doi.org/10.3350/cmh.2016.0016

Abstract
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Cirrhosis can occur with the development of portal vein thrombosis (PVT). PVT may aggravate portal hypertension, and it can lead to hepatic decompensation. The international guideline recommends for anticoagulation treatment to be maintained for at least 3 months in all patients with acute PVT. Low-molecular-weight-heparin and changing to warfarin is the usual anticoagulation treatment. However, warfarin therapy is problematic due to a narrow therapeutic window and the requirement for frequent dose adjustment, which has prompted the development of novel oral anticoagulants for overcoming these problems. We report a 63-year-old female who experienced complete resolution of recurrent acute PVT in liver cirrhosis after treatment with rivaroxaban.

Citations

Citations to this article as recorded by

The Latest Progress in Risk Factors and Anticoagulant Therapy for Portal Vein Thrombosis after Splenectomy
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Treatment of portal vein thrombosis in cirrhosis: a multicenter real life cοhort study
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Portal Vein Variations, Clinical Correlation, and Embryological Explanation: A Review Article
Gareema Tyagi, Roshan K Jha
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Treatment of acute exacerbation of liver-cirrhosis-associated portal vein thrombosis with direct-acting oral anticoagulant, edoxaban, used as an initial treatment in the early postoperative period after abdominal surgery: a case report
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Usage of Direct Acting Oral Anticoagulants in Cirrhotic and Non-Cirrhotic Portal Vein Thrombosis: A Systematic Review
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Clinical case of chronic portal vein thrombosis
L. Zaklyakova, B. Levitan, M. Bolgova, V. Skvortsov, I. Zaklyakov
Terapevt (General Physician).2020; (2): 27. CrossRef
New Insights into the Pathogenesis, Risk Factors, and Treatment of Portal Vein Thrombosis in Patients with Cirrhosis
Oana Nicoară-Farcău, Guillem Soy, Marta Magaz, Anna Baiges, Fanny Turon, Angeles Garcia-Criado, Marta Barrufet, Marta Burrel, Virginia Hernández-Gea, Juan Carlos García-Pagán
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Kyle A. Davis, Charles R. Puleo, Alexander J. Kovalic, Sarah A. Nisly
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Direct Oral Anticoagulants in Chronic Liver Disease
Taylor D. Steuber, Meredith L. Howard, Sarah A. Nisly
Annals of Pharmacotherapy.2019; 53(10): 1042. CrossRef
Update on Management of Portal Vein Thrombosis and the Role of Novel Anticoagulants
Matthew Wu, Michael Schuster, Micheal Tadros
Journal of Clinical and Translational Hepatology.2019; 7(X): 1. CrossRef
Portal vein thrombosis in cirrhosis: Why a well-known complication is still matter of debate
Mariella Faccia, Maria Elena Ainora, Francesca Romana Ponziani, Laura Riccardi, Matteo Garcovich, Antonio Gasbarrini, Maurizio Pompili, Maria Assunta Zocco
World Journal of Gastroenterology.2019; 25(31): 4437. CrossRef
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Emmanuelle De Raucourt, A. Poujol-Robert, Dominique Valla, Pierre-Emmanuel Rautou
Revue de biologie médicale.2019; nº350(5): 5. CrossRef
Rivaroxaban and Apixaban for Initial Treatment of Acute Venous Thromboembolism of Atypical Location
Dawid T. Janczak, Malgorzata K. Mimier, Robert D. McBane, Patrick S. Kamath, Benjamin S. Simmons, Dalene M. Bott-Kitslaar, Charles J. Lenz, Emily R. Vargas, David O. Hodge, Waldemar E. Wysokinski
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Clinical significance of small‐bowel villous edema in patients with liver cirrhosis: A capsule endoscopy study
Ichiro Otani, Shiro Oka, Shinji Tanaka, Akiyoshi Tsuboi, Sayoko Kunihara, Yuko Nagaoki, Hiroshi Aikata, Kazuaki Chayama
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Eran Zimran, Ronald Hoffman, Marina Kremyanskaya
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Timing of anticoagulation for portal vein thrombosis in liver cirrhosis: An Italian internist’s perspective
Nicoletta Riva, Walter Ageno
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Newer Oral Anticoagulants in the Treatment of Acute Portal Vein Thrombosis in Patients with and without Cirrhosis
P. Priyanka, J. T. Kupec, M. Krafft, N. A. Shah, G. J. Reynolds
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238 Download
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Review

Hepatic neoplasm

New perspectives on the management of hepatocellular carcinoma with portal vein thrombosis: Hyun Young Woo, Jeong Heo; Clin Mol Hepatol 2015;21(2):115-121.
Published online June 26, 2015; DOI: https://doi.org/10.3350/cmh.2015.21.2.115

Abstract
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Despite advances in the treatment of hepatocellular carcinoma (HCC), managing HCC with portal vein thrombosis (PVT) remains challenging. PVT is present in 10-40% of HCC cases at the time of diagnosis and its therapeutic options are very limited. Current guidelines mainly recommend sorafenib for advanced HCC with PVT, but surgery, transarterial chemoemolization, external radiation therapy, radioembolization, transarterial infusion chemotherapy, and combination therapy are also still used. Furthermore, several new emerging therapies such as the administration of immunotherapeutic agents and oncolytic viruses are under investigation. This comprehensive literature review presents current and future management options with their relative advantages and disadvantages and summary data on overall survival.

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Frontiers in Oncology.2024;[Epub] CrossRef
Comments on Comparison of Sorafenib versus Hepatic Arterial Infusion Chemotherapy-Based Treatment for Advanced Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis: Reply
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Case Report

A Case of Extrahepatic Portal Vein Thrombosis Treated by Transjugular Intrahepatic Portosystemic Shunt (TIPS): Young Tak Kim , Hyek Man Kwen , Min Su Kum , Chang Hyeong Lee , Young Oh Kwen , Sung Kook Kim , Yong Hwan Choi , Joon Mo Chung; Korean J Hepatol 1997;3(1):65-69.

Abstract
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Portal vein occlusion has previously been considered as a contraindication for TIPS placement. Several recent reports have suggested that placement of TIPS may be effective in patients with occluded portal veins to embolize varices and recanalize venous obstruction. We experienced a case of variceal bleeding associated with portal vein thrombosis who was success- fully treated with TIPS placement. So we report the case with a brief review of literatures.

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Original Articles

Concurrent Chemo - Radiation Therapy for Advanced Hepatocellular Carcinoma with Portal Vein Thrombosis: Jin Suk Kim, M.D., Kwang-Hyub Han, M.D., Do Yun Lee, M.D.* , Jin-Sil Seong, M.D.† , Young Hoon Youn, M.D., Jae Youn Cheong, M.D., Sang Hoon Ahn, M.D., Chae Yoon Chon, M.D., and Young Myoung Moon, M.D.; Korean J Hepatol 2002;8(1):71-79.

Abstract
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Background/Aims
Advanced hepatocellular carcinoma with portal vein thrombosis has a poor prognosis. This study was undertaken to evaluate the therapeutic effects of concurrent chemo-radiation therapy in advanced hepatocellular carcinoma with portal vein thrombosis. Methods: A total of 54 patients with advanced hepatocellular carcinoma (TNM stage IVa) were enrolled. Nineteen patients were treated with external beam radiotherapy (4,500 cGy/ 5 weeks) and intrahepatic arterial 5-FU infusion (500 mg on 1-5 day and 30-35 day, respectively) via implanted chemoport. The others were treated with intrahepatic arterial cisplatin infusion (80 mg/m²). Results: In patients treated with concurrent chemo-radiation therapy, response rates at 2nd and 6th months were 42.1% and 26.3%, respectively. In patients treated with intrahepatic arterial cisplatin therapy, response rates at 2nd and 6th months were 2.9% and 0%, respectively. The median survival time was 11.6 months in concurrent chemo-radiation therapy and 4.8 months in intrahepatic arterial cisplatin infusion therapy. Concurrent chemo-radiation therapy produced better response rates and longer survival time than those of intrahepatic arterial cisplatin infusion therapy (p<0.05). Conclusions: Concurrent chemo-radiation therapy achieved favorable results in advanced hepatocellular carcinoma with portal vein thrombosis and can be considered as a treatment option for the management of advanced hepatocellular carcinoma.(Korean J Hepatol 2002;8:71-79)

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Effect of Transjugular Intrahepatic Portosystemic Shunt for Variceal bleeding in Hepatocellular Carcinoma Patients with Portal Vein Thrombosis: Woo Jin Chung, M.D., Byung Kuk Jang, M.D., Kyung Sik Park, M.D., Kwang Bum Cho, M.D., Jae Seok Hwang, M.D., Sung Hun Ahn, M.D., Yong Hoon Kim, M.D.1, Young Hwan Kim, M.D.2 and Yong Ju Kim, M.D.3; Korean J Hepatol 2005;11(2):157-163.

Abstract
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Background/Aims
Transjugular Intrahepatic Portosystemic Shunt (TIPS) is commonly used in patients with variceal bleeding. However, this procedure is contraindicated in hepatocellular carcinoma patients with portal vein thrombosis. This study was done to evaluate the effect of TIPS in those patients with variceal bleeding. Methods: Between 1997 and 2004, six hepatocellular carcinoma (HCC) patients with portal vein thrombosis were enrolled in this study due to their variceal bleeding. All the patients underwent TIPS placement to treat the variceal bleeding that had not responded to endoscopic treatment. Effective shunt creation was assessed by the decrease of the portal pressure gradient (less than 12 mmHg) or if good patency and flow were seen on a doppler examination. Results: Shunts were successfully created in all the patients and the bleeding was immediately controlled in the active bleeding cases. The bleeding was caused by esophageal varices in one patient and, by gastric varices in five patients. The HCC types were diffuse or massive in five patients, and a single nodule was present in one patient. All the patients had portal vein thrombosis. Rebleeding was noted in two patients at 10 days and 3 months, respectively, due to the shunt occlusion. Hepatic encephalopathy was noted in two patients. The causes of death were hepatorenal syndrome after 2 weeks in one patient, bleeding due to portal hypertensive gastropathy after 3 weeks in another, and cancer progression after 4 months in third patient. Conclusions: For HCC patients with portal vein thrombosis, TIPS can be an effective treatment modality if uncontrolled variceal bleeding presents when using endoscopic hemostasis or pharmacologic therapy. However, further studies are needed. (Korean J Hepatol 2005;11: 157-163)