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Editorial: acute non‐cirrhotic and non‐malignant portal vein thrombosis—who should be candidates for interventional treatment?

Acute non-cirrhotic and non-malignant portal vein thrombosis (PVT) is a rare medical emergency.1 Hence it is difficult to organise and conduct a large-scale, multi-centre, controlled study to evaluate this important clinical problem. To the best of our knowledge, only case series have reported the role of interventional treatment, mainly transcatheter thrombolysis, mechanical thrombectomy and transjugular intrahepatic portosystemic shunt, for acute non-cirrhotic and non-malignant PVT. Those studies demonstrated a high rate of portal vein recanalization, but still a significant proportion of patients may suffer from bleeding complications and intestinal infarction (Table 1).2-8 [Correction added on July 30, 2020 after first online publication: In the preceding sentence, "intestinal necrosis" was changed to "intestinal infarction".] Notably, due to limitations in study design, previous studies could not weigh the advantages and disadvantages of interventional vs conventional treatment. Rössle and colleagues recently reported a prospective study comparing the efficacy and safety of interventional vs medical treatment in 65 non-cirrhotic and non-malignant patients with acute PVT from nine German centres.9 They found that interventional treatment produced significantly higher rates of complete (interventional vs medical: 54% vs 30%) and partial (17% vs 7%) portal vein recanalization, but it also caused more procedure-related bleeding events (mild bleeding, 9 vs 0; intraperitoneal bleeding requiring transfusion or surgery, 2 vs 0), without a benefit of preventing from bowel gangrene requiring surgery (10% vs 15%). By comparison, the medical treatment group had a significantly lower rate of portal vein recanalization, but did not carry a higher risk of intestinal infarction requiring surgery, without any bleeding complications. [Correction added on July 30, 2020 after first online publication: In the preceding sentence, "intestinal necrosis" was changed to "intestinal infarction".] It seems that the short-term outcome of patients with acute non-cirrhotic and non-malignant PVT, which refers to thrombus progression and development of intestinal infarction, is not mainly dependent upon the recanalization of the thrombosed portal vein. [Correction added on July 30, 2020 after first online publication: In the preceding sentence, "intestinal necrosis" was changed to "intestinal infarction".] On the other hand, these investigators did not find any additional benefit of interventional treatment on the long-term outcome, which refers to complications of portal hypertension secondary to chronic PVT, such as gastroesophageal varices seen on endoscopy (53% vs 41%). Therefore, interventional treatment cannot be definitely supported in such patients, and we have to identify who would benefit more from interventional treatment. To address this critical issue, there are at least two aspects that need clarification. The first is to identify patients at a high risk of failing portal vein recanalization by medical treatment. Based on the evidence from a large European multicentre study,10 patients with ascites and splenic vein occlusion may be inappropriate for medical treatment alone, but should be actively considered for interventional treatment to maximise portal vein recanalization. The second is to identify patients at a high risk of developing procedure-related bleeding complications by interventional treatment. Unfortunately, this study found no significant correlation of bleeding complications with platelet count, INR, grade and aetiology of PVT and high-volume centre. Factors, especially those related to interventional procedures and skills, should be extensively evaluated in future. Collectively, this work by Rössle et al takes a big step forward towards optimizing the management strategy of acute non-cirrhotic and non-malignant PVT. However, many questions remain to be answered, especially the timing of medical and interventional treatment.